Medical Scribe

Medical Scribe – Pain Management office 
*perm

Position Summary
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.

Location: Clark and Linden, NJ offices
Pay: starting $18 – $22/hr 
Schedule: Monday to Friday, 8-5pm
*expected in at 7:45 to see first patients scheduled at 8am

• Possible to stay as late as 6/6:30, depending on Provider schedule for the day.
• Shifts are 8 hours 

Requirements:

• HS Diploma or GED equivalent
• Completion of a recognized medical scribe training program preferred
• Minimum of 2 years’ experience, preferably in a medical practice environment
• Knowledge of HIPPA & OSHA guidelines
• Working knowledge of medical practice management systems and electronic medical records
  • Facility utilizes ModMed, easily trainable
• Basic knowledge of computers
• Knowledge of pain medications, including opioids, and understanding of pain medication safety protocols
• Strong understanding of medical terminology, anatomy & physiology is mandatory
• Excellent verbal, written, critical thinking and interpersonal skills
• Ability to work well with physicians, employees, patients, and others
• Unquestionable commitment to confidentiality, quality customer service and professionalism
• Superior organization; attention to detail; ability to respond to requests in fast-paced environment; and prioritize tasks

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

• Assists with answering phone calls and responding to voice mails accordingly
• Maintains and respects the confidentiality of patient information in accordance with company policy & procedure, and HIPAA & compliance guidelines
• Attends all regular staff meetings and continuing education sessions as required
• Maintains regular attendance
• Presents professional image in manner, appearance, motivation, and work habits
• Performs other duties as assigned