Job Description

Position Title

: Medical Scribe - Pain Management Clinic

Reports to

: Physician/Practice Manager

Job Summary

:

The Medical Scribe in a pain management clinic is responsible for providing real-time documentation support for the healthcare providers, ensuring all patient encounters are accurately and efficiently recorded. This includes the documentation of patient histories, physical examinations, procedures, treatments, and other relevant medical information during clinical visits. The role helps the healthcare provider focus on patient care by managing the documentation, ensuring compliance with regulations, and facilitating smoother patient interactions.

Key Responsibilities

:

Real-Time Documentation

: Accurately document the patient's medical history, presenting symptoms, physician's findings, and treatment plans in real time. Document physical exams, vital signs, and relevant patient information during patient visits, ensuring accurate details are recorded. Record any medical procedures performed, including injections, nerve blocks, and other interventions typical in pain management. Update and maintain patient charts in electronic health records (EHR) systems, ensuring timely, complete, and accurate data entry.

Support During Patient Visits

: Accompany the physician during patient examinations and consultations, ensuring all information is captured in real-time. Clarify, interpret, and assist in communicating instructions to patients regarding treatment plans, medications, and follow-up care as directed by the physician. Assist in ensuring that appropriate forms and patient consent documents are completed during visits.

Data Entry and Chart Management

: Ensure that patient records are complete, updated, and compliant with all regulations, including HIPAA. Enter patient-specific data into the EHR system, including diagnostic codes, procedure codes, and medications prescribed. Review and update patient medication lists, allergies, and other critical information. Help track patient progress and follow-up requirements by maintaining updated patient charts and documentation.

Facilitate Physician Workflow

: Streamline physician workflow by removing administrative burdens related to charting and documentation, allowing the physician to focus on patient care. Communicate with the healthcare team for any required patient updates, lab results, imaging, or consultations. Assist with preparing patient files for review prior to appointments, ensuring relevant history and clinical data is easily accessible.

Billing and Coding Support

: Ensure proper documentation of procedures, consultations, and visits to assist in the accurate coding and billing process. Assist with the identification of appropriate billing codes, ensuring compliance with insurance guidelines.

Clinical Research and Documentation

: Assist in the documentation of clinical trials or other research-related activities, if applicable, to ensure patient data is accurately recorded and maintained. Document any additional pain management treatments, medication adjustments, or experimental therapies used in the clinic.

Confidentiality and Compliance

: Adhere to patient confidentiality requirements as outlined by HIPAA and other relevant healthcare regulations. Assist in ensuring the clinic complies with local, state, and federal health regulations, including proper documentation practices and patient privacy laws.

Qualifications

:

Education

: High School Diploma or equivalent required. An associate degree or higher in a healthcare-related field is preferred.

Experience

: Previous medical scribe experience, preferably in a pain management or similar clinical setting, is highly preferred. Experience with EHR systems (e.g., Epic, Cerner, or similar) is a plus.

Knowledge & Skills

: Strong understanding of medical terminology, anatomy, physiology, and common pain management treatments (e.g., injections, nerve blocks, physical therapy). Excellent listening, communication, and typing skills. Ability to work in a fast-paced environment and maintain focus and accuracy. Proficiency with electronic health records and basic office software (Microsoft Office, Google Workspace, etc.).

Certifications

: Scribe certification (e.g., from the American Healthcare Documentation Professionals Group) is a plus but not required.

Working Conditions

:

Location

: Pain Management Clinic, may involve both in-person and remote documentation if the clinic offers telemedicine services.

Physical Requirements

: Ability to sit for long periods during patient interactions, occasional travel within the clinic or between multiple locations if applicable.

Personal Attributes

:

Detail-Oriented

: Ensures that all documentation is accurate, thorough, and compliant with regulations.

Team Player

: Works effectively with physicians, nurses, and other staff members.

Professionalism

: Maintains a high level of professionalism in both interactions with patients and internal team members.

Adaptability

: Able to quickly adapt to changes in clinical workflows, technology, and healthcare regulations.

Time Management

: Capable of managing multiple tasks simultaneously and prioritizing workloads effectively.

Compensation

:

Competitive salary, commensurate with experience Benefits may include health insurance, retirement plans, paid time off, and others (specific details based on clinic policy).
Job Type: Full-time

Pay: From $15.05 per hour

Benefits:

401(k) Dental insurance Health insurance Paid time off Vision insurance
Medical Specialty:

Pain Medicine
Schedule:

8 hour shift
Ability to Commute:

Conway, AR 72034 (Required)
Ability to Relocate:

Conway, AR 72034: Relocate before starting work (Required)
Work Location: In person