Medical Scribe

We are looking for a dedicated and detail-oriented Medical Scribe to join our medical billing team. The ideal candidate will assist healthcare providers by accurately documenting patient encounters in real-time during medical consultations. The Medical Scribe will play a vital role in ensuring the accurate and efficient capture of patient information, enabling providers to focus more on patient care while ensuring compliance with medical billing standards.

Key Responsibilities:

• Documentation of Patient Encounters:
• Accurately transcribe patient history, symptoms, diagnoses, procedures, and treatment plans during medical examinations and consultations.
• Ensure timely and precise documentation of all clinical information in the Electronic Health Record (EHR) system.
• Maintain the confidentiality of patient information according to HIPAA guidelines and company policies.
• Act as a real-time documentation support for physicians, ensuring that all relevant patient information is recorded.
• Provide assistance with navigating EHR systems and other clinical tools to ensure accurate data entry.
• Collaborate with medical providers to ensure that documentation is aligned with medical billing and coding standards.
• EHR Management & Updates:
• Manage and update EHRs by ensuring accurate documentation of all patient interactions, medical histories, medications, diagnoses, and treatment plans.
• Verify and cross-check patient data to ensure it is correct and up-to-date.
• Ensure timely completion of patient charts to support the medical billing process.
• Medical Billing & Coding Support:
• Assist in the preparation of medical billing codes based on recorded documentation.
• Ensure that all procedures, diagnoses, and treatments are documented accurately to facilitate proper medical coding.
• Help ensure that claims are compliant with insurance and regulatory requirements, contributing to the timely and accurate submission of medical claims.
• Communication & Coordination:
• Communicate with healthcare providers, patients, and other medical staff to obtain any missing or unclear information.
• Collaborate with other departments (e.g., billing, coding, and patient services) to ensure accurate information flow and proper billing procedures.
• Adherence to Policies & Procedures:
• Adhere to all company policies, procedures, and regulations concerning medical documentation and confidentiality.
• Ensure that all documentation complies with HIPAA, OSHA, and other regulatory requirements.
• Stay current with medical terminology, EHR systems, and medical billing and coding practices.
• Participate in training sessions and workshops as necessary to improve scribing skills and knowledge of medical billing and coding.

Required Skills & Qualifications:

• Education & Experience:
• High school diploma or equivalent required; Associate's or Bachelor's degree in a related field preferred.
• 1-2 years of experience as a medical scribe, medical assistant, or in a healthcare setting preferred.
• Technical Skills:
• Strong understanding of medical terminology, procedures, and clinical documentation.
• Familiarity with Electronic Health Records (EHR) systems and medical documentation tools.
• Basic knowledge of medical billing and coding processes, including ICD-10, CPT, and HCPCS codes.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).
• Soft Skills:
• Excellent attention to detail and organizational skills.
• Strong communication skills, both written and verbal.
• Ability to work under pressure and meet deadlines in a fast-paced environment.
• Strong interpersonal skills and the ability to work as part of a healthcare team.
• Ability to maintain patient confidentiality and demonstrate discretion.

Preferred Qualifications:

• Experience in a medical billing or coding environment is a plus.
• Certification in medical scribing (e.g., from the American Healthcare Documentation Professionals Group, AHDPG) or similar organizations is preferred.
• Knowledge of HIPAA compliance regulations and patient privacy standards.