Medical Scribe, Pain Management

Job Type Full-time Description

 The Medical Scribe for Pain Management is a crucial member of our healthcare team, working closely with Pain Management physicians to ensure accurate and efficient documentation of patient encounters. This role bridges the gap between clinical care and administrative documentation, allowing our physicians to focus more on patient care while maintaining comprehensive medical records.

Requirements

  

KEY RESPONSIBILITIES

Clinical Documentation:

§ Document patient encounters in real-time during clinical visits, including chief complaints, history of present illness, past medical history, medications, allergies, and review of systems

§ Record physical examination findings, assessment, diagnosis, and treatment plans as dictated by the physician

§ Document pain levels using standardized scales (e.g., Numeric Rating Scale, Visual Analog Scale)

§ Accurately record details of interventional procedures, including specific techniques, medications used, and patient responses

Electronic Health Record (EHR) Management:

§ Navigate and manage the clinic's EHR system efficiently

§ Update patient records with test results, imaging reports, and consultation notes

§ Assist in creating and maintaining problem lists, medication lists, and care plans

Administrative Support:

§ Prepare referral letters, work/school excuse notes, and disability forms for physician review and signature

§ Manage prescription refills and prior authorizations under physician supervision

§ Coordinate with other healthcare providers to ensure continuity of care

§ Assist in compiling information for insurance appeals and workers' compensation cases

Quality Assurance:

§ Ensure all documentation meets regulatory standards (e.g., HIPAA compliance)

§ Participate in regular quality assurance reviews to maintain high standards of documentation

§ Stay updated on changes in medical coding and documentation requirements

SHARED DUTIES/OTHER

o Assists with answering phone calls and responding to voice mails accordingly

o Maintains and respects the confidentiality of patient information in accordance with company policy & procedure, and HIPAA & compliance guidelines

o Attends all regular staff meetings and continuing education sessions as required 

o Maintains regular attendance

o Presents professional image in manner, appearance, motivation, and work habits

o Performs other duties as assigned  

Salary Description Starting at $18.00 per hour