Job Description: Medical Scribe/Medical Records Tech

As a Medical Scribe/Medical Records Tech, you will play a crucial role in supporting healthcare providers in their documentation and administrative tasks, ensuring accurate and timely management of patient records. You will work closely with physicians, nurses, and other medical staff to capture and record clinical encounters, maintain medical records, and support the overall efficiency of the healthcare facility.

Responsibilities:

1. Accurate Documentation: Efficiently document patient encounters, medical histories, physical examinations, treatments, and other relevant information as dictated by healthcare providers. Maintain a high level of accuracy and attention to detail to ensure compliance with legal and professional standards.

2. Data Entry and Management: Organize and maintain medical records, enter information into electronic health record (EHR) systems, and follow defined protocols for managing patient data. Ensure data security and confidentiality in compliance with HIPAA and other relevant regulations.

3. Interprofessional Collaboration: Collaborate with physicians, nurses, and other healthcare providers to facilitate a smooth workflow. Communicate effectively to clarify medical terminology, assist with medical data retrieval and organization, and address any concerns or discrepancies in patient documentation.

4. Administrative Support: Assist in scheduling appointments, preparing patient charts, and retrieving patient information as needed. Handle phone calls, inquiries, and requests in a professional and courteous manner, providing accurate information or directing individuals to the appropriate department.

5. Quality Improvement: Stay updated on relevant medical and industry regulations to ensure adherence to standards and protocols. Identify opportunities for process improvement, workflow optimization, and implement changes to enhance efficiency and patient satisfaction.

6. Medical Transcription: Transcribe medical reports, operative notes, discharge summaries, and other clinical documents as required, ensuring accuracy and clarity of medical terminology and abbreviations.

Qualifications:

- High school diploma or equivalent; associate or bachelor's degree in a related field is a plus.
- Proven experience as a Medical Scribe, Medical Records Technician, or similar role is preferred.
- Familiarity with medical terminology, procedures, and documentation practices.
- Proficiency in using electronic health record (EHR) systems, Microsoft Office Suite, and other relevant software.
- Exceptional attention to detail and ability to accurately record information.
- Strong organizational, multitasking, and time management skills.
- Strong interpersonal and communication skills to effectively interact with healthcare team members and patients.
- Ability to maintain professionalism and confidentiality in a fast-paced, dynamic environment.
- Knowledge of HIPAA regulations and understanding of data privacy and security practices.
- Ability to adapt to changing technologies and workflows in the healthcare industry.

As a Medical Scribe/Medical Records Tech, you will contribute to maintaining the integrity and efficiency of patient care documentation, supporting healthcare providers in delivering high-quality and informed medical services. This is an in person position in our Sterling Heights, MI location.