Clinical Scribe

Clinical Scribe Center for Neurosciences - 3.1 Tucson, AZ Job Details Part-time 12 hours ago Qualifications Anatomy knowledge High school diploma or GED Electronic health record (EHR) management for billing and coding Typing Medical terminology Full Job Description Overview We are seeking a highly motivated and detail-oriented Clinical Scribe to work directly with our Otolaryngology (ENT) physicians. The primary role is to provide real-time documentation assistance in the electronic health record (EHR) during patient encounters, allowing the physician to focus entirely on patient care. This is an excellent opportunity for individuals interested in medicine or healthcare administration to gain clinical experience and a deep understanding of medical documentation. Key Responsibilities 1. Real-Time Medical Documentation Accompany the physician into the exam room to transcribe all elements of the patient encounter directly into the EHR system. Document the History of Present Illness (HPI) , Review of Systems (ROS) , Past Medical/Surgical/Family/Social History , and physical exam findings. Accurately record physician-dictated diagnoses , procedure notes, and follow-up instructions. Enter orders for laboratory tests, imaging studies (e.g., CT, X-ray), medications, and specialist referrals as directed by the physician. Document procedures commonly performed in an ENT office, such as otoscopy, nasal endoscopy, laryngoscopy, cerumen removal, and tympanometry. 2. Workflow Management & Efficiency Anticipate the physician's needs by preparing charts for upcoming patients, including reviewing prior notes, lab results, and imaging reports. Locate information for the physician within the EHR or other systems (e.g., hospital portal) during the visit. Manage the flow of the clinic by ensuring all documentation is completed efficiently between patient encounters, maintaining a high level of productivity. 3. Communication & Compliance Review and reconcile documentation with the physician at the end of the patient visit to ensure accuracy, completeness, and compliance with billing regulations (e.g., proper CPT and ICD-10 coding support). Maintain strict patient confidentiality in accordance with HIPAA regulations. Communicate effectively with the physician, clinical staff, and other team members regarding documentation status and workflow. Required High school diploma or equivalent. Proficiency in medical terminology, anatomy, and pathophysiology , particularly related to the Head and Neck/ENT specialty (e.g., terms like tinnitus , vertigo , sinusitis , laryngitis , cochlea , eustachian tube ). Excellent typing and computer skills with a working knowledge of EHR systems (e.g., Epic, Cerner, Athena). Exceptional attention to detail and organizational skills. Ability to work in a fast-paced environment and manage time effectively. Strong interpersonal and professional communication skills. Preferred Bachelor's degree (or current enrollment) in a pre-health field (e.g., Biology, Pre-Med, Healthcare Administration). Prior experience as a clinical scribe, medical assistant, or documented completion of a professional scribe training program.