Medical Scribe

Job Description

Job Description

Benefits:

• Free uniforms
• Training & development
• Company parties

ASAM Level 2.1 Intensive Outpatient & ASAM Level 3.1 Residential Substance Use Disorder Programs

Position Summary

The Medical Scribe provides comprehensive documentation support to physicians, nurse practitioners, physician assistants, psychiatrists, and other licensed providers within the organization's ASAM Level 2.1 Intensive Outpatient (IOP) and ASAM Level 3.1 Clinically Managed Low-Intensity Residential Treatment programs. The Medical Scribe documents patient encounters in real time, ensuring timely, accurate, and complete medical records that comply with Virginia Department of Behavioral Health and Developmental Services (DBHDS), Medicaid, HIPAA, 42 CFR Part 2, ASAM Criteria, CARF/The Joint Commission (if applicable), and organizational standards.

The Medical Scribe serves as an integral member of the multidisciplinary treatment team by promoting documentation accuracy, provider efficiency, quality improvement, and continuity of care.

Essential Duties and Responsibilities

Clinical Documentation

• Document medical and behavioral health encounters as directed by licensed providers.
• Ensure documentation supports medical necessity and payer requirements.
• Accurately record progress notes.
• Support documentation for both outpatient (ASAM 2.1) and residential (ASAM 3.1) services.

Regulatory Compliance

• Maintain documentation consistent with:
  • Virginia DBHDS regulations
  • ASAM Criteria
  • Medicaid documentation standards
  • HIPAA Privacy Rule
  • 42 CFR Part 2 confidentiality requirements
  • Organizational policies and procedures

Minimum Qualifications

• High school diploma or GED required.
• Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Medical Assisting, Nursing, Behavioral Health, Psychology, Social Work, or a related field preferred.
• One (1) year of medical scribing, medical office, behavioral health, or healthcare documentation experience preferred.
• Experience in psychiatry, addiction medicine, behavioral health, or substance use treatment preferred.

Equal Opportunity Employer

We are committed to providing equal employment opportunities to all qualified applicants and employees regardless of race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected by federal, state, or local law.