Medical Scribe

Suvida Healthcare; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Suvida Healthcare is seeking a Clinical Informatics Specialist to collaborate with the care team, ensuring accuracy and efficiency of medical documentation during patient encounters.

You will document histories, exams, tests, and treatment plans in the EHR, manage data entry and coding, and support clinicians with confidential, compliant documentation.

Bilingual English/Spanish required; willing to move between Neighborhood Centers and thrive in a fast-paced clinical environment.

Qualifications

• Minimum of 2 years of clinical experience.
• Familiarity with medical terminology, anatomy, and physiology is a plus.
• Prior Medical Scribe experience is preferred, though not obligatory.
• Proficiency with EHR systems and data entry.

Responsibilities

• Patient encounter documentation: accompany healthcare providers during visits and document all relevant information in real-time.
• EHR management: input and manage patient data while ensuring compliance and confidentiality.
• Chart review: review charts for completeness and accuracy and address discrepancies.
• Effective communication: liaise between providers and team members for information and follow-up.
• Data entry and coding: enter accurate ICD-10 and CPT codes for diagnoses and services.
• Liaison for documentation queries: ensure timely resolution of queries between coding team and providers.
• Morning huddle preparation: research patient histories and external data for the morning huddle.
• Quality metrics management: measure, analyze, and report healthcare quality metrics; close care gaps.
• Population health optimization: analyze population health and coding strategies to improve patient stratification.
• Evidence-based research: stay updated on protocols and provide revised data to the care team.
• Maintain confidentiality: adhere to HIPAA and preserve patient privacy.

Skills

EHR proficiency

Medical terminology

Bilingual English/Spanish

Strong typing

Education

Bachelor’s degree in healthcare or related field

Tools

EHR software

Job description

What You’ll Do

Position Summary

The Clinical Informatics Specialist (CIS) collaborates with Suvida Healthcare primary care providers and assumes a vital role within the Care Team. The primary focus is on ensuring the accuracy and efficiency of medical documentation during patient encounters. Working closely with primary care providers, the CIS scribes and records medical histories, physical examinations, diagnostic tests, treatment plans, and other pertinent information into electronic health record (EHR) systems. The CIS’s support empowers healthcare professionals to allocate more time to patient care while maintaining comprehensive and precise patient records. Essential key responsibilities consist of but are not all inclusive:

Responsibilities

• Patient Encounter Documentation : Accompany healthcare providers during patient visits and accurately document all relevant medical information, including medical histories, physical examinations, diagnostic tests, and treatment plans in real-time.
• EHR Management : Navigate and proficiently utilize electronic health record (EHR) systems to input and manage patient data, ensuring that all documentation adheres to compliance and confidentiality standards.
• Chart Review : Regularly review and organize patient charts, ensuring completeness and accuracy of information, and addressing inconsistencies or discrepancies.
• Effective Communication : Act as a liaison between healthcare providers and other team members, facilitating the exchange of important information, requests, and follow-up instructions.
• Data Entry and Coding : Enter accurate ICD-10 and CPT codes for diagnoses, procedures, and services provided during patient encounters.
• Liaison for Documentation Queries : Serve as a liaison between the coding team and providers to ensure the timely resolution of documentation queries.
• Morning Huddle Preparation : Conduct thorough research of patients’ historical charts and external data to enhance the morning huddle presentation.
• Quality Metrics Management : Oversee measurement, analysis, and reporting of healthcare quality metrics. Identify and close gaps in care to ensure optimal outcomes.
• Population Health Optimization : Analyze population health and coding strategies to enhance patient stratification, identifying at-risk patients and assisting in enrolling them in chronic care management protocols.
• Evidence-Based Research : Stay updated on evidence-based medical protocols and provide revised data to the care team.
• Maintain Confidentiality : Adhere to strict patient privacy and confidentiality regulations (e.g., HIPAA) and ensure that all patient data is handled with the utmost discretion.

What You’ll Bring

Knowledge, Skills, and Abilities

• Bachelor’s degree in healthcare or related field, preferred.

Education, Experience, Licensure, or Certification Requirements

• Minimum of 2 years of clinical experience.
• Familiarity with medical terminology, anatomy, and physiology is a plus.
• Prior experience as a Medical Scribe is preferred, though not obligatory.
• Ability to efficiently use electronic health record (EHR) systems.
• Strong typing skills and advanced computer proficiency.
• Effective written and verbal communication skills.
• Ability to thrive in a fast-paced clinical environment with a commitment to accuracy.
• Strong organizational skills, effective time management, and problem-solving capabilities.
• Willingness to move between Neighborhood Centers as needed.
• Proficiency in both English and Spanish is required.

Suvida Healthcare provides equal employment opportunities to all Team Members and applicants for employment and prohibits discrimination and harassment of any typewithregard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.