Medical Scribe - Full Time

Description

Position Summary:

The Clinical Support Specialist will participate in the documentation of healthcare records for patients under the direction of on-staff providers while maintaining compliance with clinic, State, and National policies, procedures, rules, and regulations.

Duties and Responsibilities:

• Support the creation of accurate and timely clinical documentation during patient encounters using AI-enabled documentation tools and the electronic medical record (EMR), including HPI, ROS, physical exam findings, and provider observations.
• Review AI-generated encounter documentation for completeness, clarity, and internal consistency and flag discrepancies or items requiring provider clarification. 
• Prepare clinical documentation for provider review and signature.
• Enter and queue laboratory, imaging, medication, and prescription orders for provider review and approval.
• Process and document lab results, diagnostic testing, and provider interpretations within the electronic medical record (EMR).
• Assist with patient discharge workflows, including entering diagnoses, preparing discharge instructions, printing patient paperwork, work notes, and school excuses, and completing discharge documentation in the EMR
• Support patient flow by updating patient status, facilitating timely discharges, and helping reduce door-to-door visit times.
• Communicate with patients regarding wait times, test results, care updates, and provider-directed follow-up information.
• Assist with pharmacy management activities, including updating pharmacy information and supporting prescription processing.
• Manage provider inbox tasks, telephone encounters, patient callbacks, and other routine communications.
• Enter procedure documentation, medication administration records, injection orders, and EKG interpretations as directed by providers.
• Assist clinical staff with laboratory operations and specimen processing when needed.
• Answer incoming clinic phone calls and route requests appropriately.
• Collaborate with providers, nurses, technicians, and administrative staff to improve clinic efficiency and patient experience.
• Serve as a workflow support resource, allowing providers to focus on direct patient care while maintaining timely and accurate documentation.
• Monitor outstanding clinical documentation, orders, results, patient communications, and other provider-directed tasks and facilitate timely completion or escalation to the appropriate team member.
• Additional duties as assigned

Requirements

Education: 

• High School Diploma or equivalent. 
• Licenses/Certification: 
• Must obtain and maintain a current certification in BLS. 

Experience: 

• Healthcare experience preferred. 

Skills: 

• PC skills or applicable computer experience. 
• Ability to accurately read and write medical terminology. 
• Ability to work all shifts. 
• Ability to escort or transport patient by wheelchair or stretcher. 
• Detail-oriented with excellent interpersonal communication skills. 

Working Conditions: 

• May be exposed to/occasionally exposed to patient elements. 
• Subject to varying and unpredictable situations and interruptions. 
• Occasionally subjected to irregular hours. 
• Occasional pressure due to a fast-paced environment. 
• The position may require lifting, carrying, or pushing equipment or patients. 

Physical Requirements: 

• Must be able to see with corrective eyewear. 
• Must be able to hear clearly with assistance. 
• May be exposed to infectious and contagious diseases. 
• May be in contact with patients under a wide variety of circumstances. 
• Able to handle emergency or crisis situations. 
• Will be required to wear protective equipment as necessary. 
• Ability to escort or transport patient by wheelchair or stretcher 
• Frequently: Sitting, walking, standing. 
• Occasionally: Bending, squatting, climbing, kneeling, twisting, lifting, carrying, pushing, traveling. 
• Ability to lift 15-20 pounds