Company Overview:
GoLean Health is an innovative and rapidly expanding company dedicated to transforming the health and wellness industry. Our mission is to empower individuals to lead healthier lives through cutting-edge technology, personalized health solutions, and actionable insights.
Job Overview:
A Virtual Medical Scribe is responsible for accurately and efficiently documenting patient encounters into electronic health records (EHR) systems on behalf of healthcare providers. This includes listening to patient visits and provider-patient interactions remotely, usually via a secure audio-video connection, and entering relevant medical history, examination findings, diagnoses, treatment plans, and other pertinent information into the EHR. The goal is to alleviate the administrative burden on healthcare providers, allowing them to focus more on patient care.
Key Responsibilities:
- Live Documentation:*Accurately document the details of the patient's visit and the clinician's interaction with the patient in real-time into the EHR system, including history of present illness, physical examination results, diagnoses, treatment plans, and follow-up instructions.
- Review and Update Medical Records: Ensure that patient records are complete, accurate, and up-to-date by reviewing past records and updating them with new information as necessary.
- Collaborate with Healthcare Providers: Work closely with physicians and other healthcare providers to clarify any information and ensure the accuracy of the medical records.
- Compliance and Confidentiality: Maintain strict confidentiality of patient information in accordance with HIPAA guidelines and other relevant regulations. Ensure documentation is compliant with healthcare laws, policies, and procedures.
- Administrative Support: Perform related administrative tasks as needed, such as managing lab results, assisting with referral processing, and facilitating prescription orders under the direction of the healthcare provider.
Skills and Qualifications:
- Education: Must be a Registered Nurse; has a background in healthcare, such as a degree in a health-related field or certification as a medical scribe, is highly beneficial.
- Experience: Previous experience in a medical scribe role or similar position is preferred. Familiarity with medical terminology, procedures, and documentation practices is essential.
- Technical Skills: Proficient in using EHR systems (Athenahealth) and comfortable with remote communication technology. Fast and accurate typing skills are crucial.
- Attention to Detail: Ability to accurately capture detailed medical information and transcribe it efficiently.
- Communication Skills: Excellent listening skills and the ability to communicate effectively with healthcare professionals.
- Confidentiality: Strong understanding of and adherence to patient privacy laws and ethical standards (HIPAA) .
Work Environment:
- Remote work from home or any private, quiet, and secure location.
- Requires a reliable internet connection and possibly specific equipment provided by the employer (e.g., computer, headset).
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