MEDICAL SCRIBE

Complete Health; Westminster (CO); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading health organization is seeking a full-time Medical Scribe in Westminster, CO. The role involves documenting patient encounters, maintaining accurate medical records, and working closely with healthcare providers to ensure efficient patient care. Strong attention to detail and proficiency in medical terminology are essential.

Qualifications

• Proficient in medical terminology and clinical workflows.
• Experience using an electronic health record is required.
• Able to work in fast-paced and occasionally stressful environments.

Responsibilities

• Document patient interactions and maintain electronic health records.
• Assist healthcare providers with charting and data entry.
• Ensure patient confidentiality and compliance with HIPAA regulations.

Skills

Medical terminology

Strong verbal communication

Detail oriented

Tools

Electronic health records

Job description

Location : 3520 W 92nd Ave #104 Westminster, CO 80031

Pay Range : $19.50 - 223.59 per hour; depending on experience.

SUMMARY OF JOB DUTIES :

A scribe is responsible for assisting healthcare providers by accurately documenting patient encounters and maintaining detailed medical records. The role involves working directly with physicians or other clinical staff to ensure thorough and precise documentation of patient histories, exams, diagnoses, treatments, and other medical information. This helps healthcare providers focus on patient care, improve clinical efficiency, and support quality patient outcomes. This is a full-time position , Monday- Friday, with occasional Saturdays on a rotation basis.

• Record detailed information from a patient's visit with a provider including :
• Patient medical history and physical exam
• Procedures and treatments performed by healthcare professionals including medical assistants
• Patient education and explanations of risks and benefits
• Physician dictated diagnoses, prescriptions and instruction for patient or family members for self-care and follow-up
• Assist with referrals if directed by the physician
• Assist provider with locating test results and patient records from emergency room visits and other providers
• Work directly with a single provider
• Perform documentation in the EHR
• Partner with provider to deliver excellent patient care
• Check for accurate information in the medical record to reduce errors

KEY RESPONSIBILITIES :

• Real-Time Documentation : Document patient interactions, including history, physical exams, and clinical findings, in real time during patient visits.
• Record Maintenance : Update and manage electronic health records (EHR) with patient information, lab results, diagnoses, and treatment plans.
• Assist with Charting : Record procedures, test results, and prescribed medications in the medical chart to ensure accurate and complete medical histories.
• Data Entry and Coding : Support accurate medical coding by entering relevant clinical data and ICD / CPT codes where appropriate.
• Administrative Support : Coordinate follow-up appointments, send lab orders, or provide other clerical support as needed.
• Confidentiality and Compliance : Maintain patient confidentiality and comply with HIPAA regulations, as well as institutional policies regarding patient care documentation.

MINIMUM REQUIREMENTS

• Proficient in medical terminology, anatomy, and clinical workflows.
• Experience using an electronic health record
• Enthusiastic, have a positive attitude and a great work ethic
• Strong verbal and written communication skills for professional interactions.
• Ability to work in fast-paced environments and adapt to changing clinical needs.
• Detail oriented and a problem solver
• Flexible
• Ability to take direction from, and work well with, others
• Ability to work well in occasionally stressful situations

WORKING ENVIRONMENT

The position requires climbing, stooping, kneeling, crouching, reaching, standing, lifting, grasping, feeling, talking, hearing, repetitive motions, and finger use. Pushing and pulling are occasionally required. Use of a computer, keyboard, and telephone along with various office machines is an essential part of the job.

DISCLAIMER

The above statements are intended to describe the general nature and level of work being performed by the Scribe. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. The Scribe may be required to perform duties outside of their normal responsibilities from time to time as needed or as directed by supervision.

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Medical Scribe • Westminster, CO, United States