Job Summary:
The Medical Scribe – will support healthcare providers by reviewing patient charts and accurately transcribing/documenting them into EHR system. This is a non–real-time scribing role focused on chart transfer, clinical interpretation, and accurate documentation, carried out during Indian Day Shift.
Key Responsibilities:
- Review patient encounters, consultation notes, diagnostic reports, and documentation.
- Interpret clinical sections including HPI, ROS, Physical Examination, Past Medical History, Assessment & Plan, medications, lab results, and imaging summaries.
- Cross-check clinical data such as allergies, diagnoses, vitals, and orders before finalizing the chart.
- Enter structured and unstructured data into the EHR following guidelines.
- Ensure accuracy, completeness, and standardization of all documentation.
- Communicate with the supervisor for clarification of ambiguous or incomplete information.
- Ensure patient data confidentiality following HIPAA or organizational requirements.
- Meet productivity and quality standards consistently.
Required Qualifications:
- Bachelor's degree in Life Sciences, Biotechnology, Nursing, Physiotherapy, Pharmacy, or related fields.
- Strong understanding of Anatomy & Physiology, medical terminology, and clinical concepts.
- Excellent written communication skills in English.
- Previous healthcare experience such as Medical Scribe, Medical Document Reviewer, Medical Biller, etc
- Ability to analyze physician notes and medical content with accuracy.
- Proficient typing speed (40 WPM preferred).
- Strong attention to detail and ability to maintain documentation consistency.
Preferred Skills:
- Familiarity with CPT, ICD-10, and HCPCS coding.
- Understanding US healthcare workflow.
