Clinical Documentation Specialist - Medical Scribe

Clinical Documentation Specialist / Medical Scribe

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.

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.

Responsibilities Include:

• 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.

Requirements

Minimum Knowledge, Skills, Abilities and Experience:

• 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

Desirable Knowledge, Skills, Abilities and Experience:

• 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.

Physical Requirements Include:

• Frequent: Repetitive keyboard use, hand motions
• Precise: auditory and visual acuity
• Ability: stand for extended periods of time and push a mobile computer cart

Other Information:

Successful incumbents are committed team players who are self-motivated, highly organized, and comfortable working in a busy medical office environment. This position offers an excellent opportunity for individuals seeking a career in medicine to increase their knowledge and experience in healthcare and enhance their potential to further their education in the medical field. This position is full-time, 40 hours per week, and will work Monday through Thursday 7:30 am to 5:00 pm and Friday 7:30 am to 11:30 am. The Medical Scribe is assigned to a specific physician; they will typically work at two Richmond-area clinic locations. If traveling between offices during the workday, employees are paid for travel time and mileage.

Full benefits package including competitive compensation, health insurance, PTO, retirement plan and personal development support.

We are an Equal Opportunity Employer and are committed to a diverse and inclusive workplace.