Clinical Documentation Specialist - Medical Scribe
About The Position
Virginia Urology will provide access to individualized, quality, and compassionate urological care from a highly specialized and diverse teams while maintaining a fulfilling work environment. The Clinical Documentation Specialist / Medical Scribe prepares for patient visit, accurately gathers and documents healthcare data during examination and treatment of patients under the direction of a physician and clinical team. Using electronic medical records system (EMR), organizes healthcare data and reference data sources in support of clinic workflow to provide efficiency of clinical care while adhering to practice protocols and processes.
Requirements
- 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
Nice To Haves
- Prior medical office or other health facility experience supporting multiple clinicians.
- Experience with data entry into an electronic medical records system
- Associate or bachelor’s degree in applied sciences preferred.
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.
Benefits
- health insurance
- PTO
- retirement plan
- personal development support
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
