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Healthcare Scribe

2 months ago

Arlington, Virginia, United States Resurgens Orthopaedics Full time

Position Overview: This full-time role is designed for an individual responsible for documenting office visit notes for healthcare providers. The position involves collecting pertinent information during patient examinations and compiling it into comprehensive medical reports, correspondence, and other administrative documents that contribute to the patients' permanent records. This work is performed within a clinical setting.

Key Responsibilities:

  • Collects detailed information while accompanying the physician and patient during consultations.
  • Edits documentation for accuracy, grammar, and clarity.
  • Capable of compiling various medical documents, including discharge summaries, physical examination reports, operative notes, consultation summaries, autopsy findings, diagnostic imaging results, progress notes, and referral letters.
  • Submits completed documents to physicians or other healthcare professionals for review and necessary adjustments.
  • Performs additional tasks as needed, such as greeting patients, faxing, scanning, mailing correspondence, answering phone calls, and managing incoming mail.
  • Inputs ICD-10 codes, CPT codes, and modifiers to ensure precise claims processing.
  • Places orders critical to patient care, including prescriptions, therapy sessions, and additional diagnostic testing/imaging.

Qualifications:

  • Familiarity with medical terminology, human anatomy, diagnostic procedures, pharmacology, and treatment evaluations (on-the-job training will be provided).
  • Ability to interpret medical jargon and abbreviations into their full forms using both electronic and printed medical reference materials.
  • Understanding of medical record protocols and the legal and ethical standards associated with maintaining patient confidentiality.