Medical Scribe & Clinical Documentation Specialist

Socket.dev; Stevens Point (WI); On-site; USD 21,000 - 29,000; Full time

Benefits offered by this job

Full benefits package including health

PTO

Retirement plan

Personal development support

Job summary

Virginia Urology seeks a Clinical Documentation Specialist / Medical Scribe to support patient visits and accurately gather and document healthcare data under physician supervision.

You will abstract information, enter records into EMR, coordinate prescriptions and referrals, and assist in rapid, precise documentation to enhance clinic workflow and patient care across two Richmond-area locations.

Qualifications

• Proficiency with Microsoft Office.
• Highly detail-oriented with the ability to multi-task.
• Knowledge of medical terminology or applied health sciences.
• Ability to type a minimum of 65 words per minute while maintaining accurate spelling, grammar, and punctuation.
• Ability to summarize complex medical information in a clear, concise, accurate manner to produce professional transcription at a high rate of output.
• Outstanding interpersonal skills and ability to work well with team members.
• Ability to maintain strict patient confidentiality.
• High school diploma or GED.

Responsibilities

• Gathers information from multiple sources including recent health records from external providers and facilities in preparation for patient clinic visits.
• Under the supervision of a physician, abstracts patient information from the chart in preparation for the upcoming patient visit and enters the information into the EMR.
• Assists the physician and nurse during clinic visits by entering an accurate, complete record of the patient encounter in real-time into the EMR. This includes the patient’s medical history, complaint, symptoms, physical exam, physician’s assessment and treatment plan, post-visit documentation, and follow-up instructions. Entry is reviewed and approved by the provider.
• Under the provider’s supervision, coordinates electronic prescriptions, submits referrals to other medical specialists, and enters laboratory test and imaging orders to facilitate the provider’s treatment plan for the patient.
• Enhances clinic efficiency by escorting patients to exam rooms, checking out patients and making follow-up appointments at the conclusion of the clinic visit, and cleaning and restocking exam rooms between patients to maintain a clean, productive work environment.
• Imports charges from patient’s clinic visits into the EMR, including accurate diagnostic and procedure codes.
• Under the provider’s supervision, tracks lab and imaging tests and reports results to healthcare professionals.
• Perform other duties as assigned in support of clinical excellence, operational effectiveness and patient-centered care.

Skills

Microsoft Office

Detail-oriented

Medical terminology

Typing 65 wpm

Summarize medical info

Interpersonal skills

Patient confidentiality

Education

High school diploma or GED

Associates or Bachelor's in applied sciences preferred

Tools

EMR system

Job description

Virginia Urology seeks a Clinical Documentation Specialist / Medical Scribe to support patient visits and accurately gather and document healthcare data under physician supervision.

You will abstract information, enter records into EMR, coordinate prescriptions and referrals, and assist in rapid, precise documentation to enhance clinic workflow and patient care across two Richmond-area locations.