Medical Scribe

Live Medical Scriber

We’re seeking a Medical Scriber who is ready to work with new technologies and help our

providers with saving time and money. The ideal candidate has experience using the EHR

to scribe visitation notes into the patient’s chart while understanding the difference

nuances between multiple providers in real time.

Objectives of this role

Responsibilities

• Reviews Physician dictation and transcribes to clinical notes in EMR/Billing

systems

• Prepares and assembles medical record documentation/charts for physician(s).

• Ensures medical record compliance by self-documentation attestation.

• Updates patient history, physical exam, and other pertinent health information in

the patient

• Prepares and sends all documentation to physicians for review and approval via

authentication of detailed data entry and facility-specific procedures.

• Monitors the duration of basic lab results and screening procedures.

• Complies with hospital and medical facility policies, including those relating to

HIPAA and Joint Commission.

• Performs other clerical duties and tasks to improve provider productivity and

clinic workflow as assigned.

• Assign codes to diagnoses and procedures, using ICD (International

Classification of Diseases) and CPT (Current Procedural Terminology) codes

• Ensure codes are accurate and sequenced correctly in accordance with

government and insurance regulations

• Follow up with the provider on any documentation that is insufficient or unclear

• Communicate with other clinical staff regarding documentation

• Search for information in cases where the coding is complex or unusual

• Receive and review patient charts and documents for accuracy

• Review the previous day's batch of patient notes for evaluation and coding

• Ensure that all codes are current and active

Required skills and qualifications

• 3-5 years of experience as a Live Medical Scriber

• Administrative writing skills

• Reporting skills

• Organizational skills

• Record-keeping

• Microsoft Office skills

• Professionalism, confidentiality, and organization

• Typing

• Solid oral and written communication skills

• Education, Experience, and Licensing Requirements:

• Medical coding or successful completion of a certification program

• Bachelor’s degree with pre-health career track preferred

• Strong knowledge of anatomy, physiology and medical terminology

• Familiarity with ICD-X codes and CPT Procedures

• Skilled in operating various medical record software and hardware, word-

processing, and database software programs