Medical Scribe

Medical Scribe

Monday-Friday 8AM-5PM

Tulsa, OK

$17-$21/hour DOE

Medical Scribe Job Summary:

The Scribe is a support role and is responsible for playing a vital role in supporting healthcare providers by accurately documenting patient encounters in real-time. The incumbent will report to the Office Manager (or similar role) and will work closely with providers to facilitate 5-star service of care to our patients. Scribe

Medical Scribe Responsibilities:

• Accurately document patient encounters, including medical histories, physical examinations, procedures, and treatment plans, in real-time
• Ensure thorough and organized documentation in the electronic health record system -Assist healthcare providers with documentation, allowing them to focus on patient care
• Anticipate the needs of providers during examinations, procedures, and consultations
• Facilitate communication between healthcare providers, nursing staff, and other members of the healthcare team -Collaborate with providers to clarify and complete medical documentation
• Enter relevant patient data into the EHR system accurately and efficiently
• Maintain patient confidentiality and adhere to privacy regulations
• Participate in quality assurance activities to ensure the accuracy and completeness of medical documentation
• Collaborate with providers to address any discrepancies or missing information
• Additional duties as assigned

Medical Scribe Requirements/Skills:

• Bachelors degree in a healthcare related field or relevant experience
• Previous experience as a Medical Scribe is preferred
• Detail oriented with a commitment to accuracy and thorough documentation
• Working knowledge with Google Suite (Drive, Docs, Sheets, Slides) and Microsoft Office (Word, Excel, PowerPoint) for real-time collaboration

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* Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. Classify medical and healthcare concepts, including diagnosis, procedures, medical services, and equipment, into the healthcare industry's numerical coding system. Includes medical coders.

* Transcribe medical reports.

* Schedule medical appointments for patients.

* Review records for completeness, accuracy, and compliance with regulations.

* Scan patients' health records into electronic formats.

* Retrieve patient medical records for physicians, technicians, or other medical personnel.

* Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings.

* Release information to persons or agencies according to regulations.

* Post medical insurance billings.

* Process and prepare business or government forms.

* Process patient admission or discharge documents.

* Protect the security of medical records to ensure that confidentiality is maintained.

* Maintain or operate a variety of health record indexes or storage and retrieval systems to collect, classify, store, or analyze information.

* Identify, compile, abstract, and code patient data, using standard classification systems.

* Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.

* Consult classification manuals to locate information about disease processes.

* Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.

* Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software.