Back Office (Medical Records)

Position Overview The Medical Scribe supports healthcare providers by accurately documenting patient encounters in real time within the Electronic Health Record (EHR). This role enables providers to focus on patient care while ensuring clinical documentation is complete, accurate, and compliant with regulatory and organizational standards.
Responsibilities
• Clinical Documentation:
• Document provider-patient encounters accurately and in real time during clinic visits.
• Record patient history, physical exam findings, assessments, and treatment plans as dictated by the provider.
• Enter orders for tests, medications, and procedures under direct provider instruction.
• Ensure all documentation complies with regulatory, legal, and payer requirements.
• Chart Preparation & EHR Management:
• Review patient charts and prior records before appointments.
• Update charts with relevant history, labs, imaging, and supporting documents.
• Ensure records are complete and ready for provider review and sign-off.
• Maintain timely and accurate chart closure.
• Communication & Compliance:
• Communicate effectively with providers and clinical staff as needed.
• Handle sensitive patient information in compliance with HIPAA regulations.
• Follow all documentation and confidentiality standards.
Skills
• High school diploma or equivalent required; higher education preferred (Chemistry, Biology, or any medical-related field).
• Prior medical scribe or clinical documentation experience preferred.
• Strong knowledge of medical terminology and clinical workflows.
• Excellent listening, typing, and attention to detail.
• Proficiency with EHR systems.
• Ability to work in a fast-paced clinical environment.

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