Job Description
POSITION SUMMARY:
The Medical Scribe supports licensed practitioners (physicians, NPs, PAs, psychologists, and clinical teams) by performing real time, accurate documentation of patient encounters in the electronic health record (EHR). This role requires advanced attention to detail, fluency in behavioral health and neurodevelopmental terminology, adherence to compliance standards (i.e. HIPAA, CMS documentation), and a compassionate, family centered approach to care coordination for patients with complex medical and behavioral needs.
JOB-SPECIFIC RESPONSIBILITIES:
• Service
o Consistently supports and communicates the Mission, Vision, and Values of Nexus Health Systems
o Upholds the Standards of conduct and corporate compliance
o Demonstrates honest behavior in all matters. To the best of the employee's knowledge and understanding, complies with all Federal and State laws and regulations.
o Maintains the privacy and security of all confidential and protected health information. Uses and discloses only that information which is necessary to perform the function of the job.
o Adheres to all Nexus Health Systems policies on Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
o Collaborates effectively with colleagues and other departments to ensure seamless service delivery.
• Excellence
o Accurately document patient encounters in real time under provider direction, ensuring completeness and timeliness in the EHR.
o Maintain high standards of documentation accuracy, compliance with Association for Healthcare Documentation Integrity (AHDI) guidelines, and proper EHR security practices.
o Apply advanced knowledge of neurodevelopmental and behavioral health terminology to ensure precise and clinically relevant documentation.
o Support providers by preparing encounter templates and retrieving prior records to optimize workflow efficiency.
o Demonstrate strict adherence to HIPAA and organizational policies while ensuring data integrity and confidentiality.
• Patient Experience and Advocacy
o Capture family concerns and care coordination details while safeguarding privacy and supporting clear communication of care plans.
o Document individualized treatment goals and progress to reflect patient-centered care and medical necessity.
o Facilitate accurate recording of caregiver input and multidisciplinary recommendations to enhance continuity of care.
o Ensure documentation promotes clarity in discharge instructions and educational materials for families.
• Quality Assurance and Compliance
o Ensures all activities adhere to healthcare regulations and organizational policies.
o Participates in quality improvement initiatives to enhance service delivery.
o Promotes a culture of patient safety which results in the identification and reduction of unsafe practices.
o Ensure all scribed notes include proper identification and provider attestation and participate in audits to maintain regulatory compliance.
• Professional Growth and Continuing Education
o Completes annual education requirements.
o Maintains competency, as evidenced by completion of competency validation requirements.
o Maintains competency and knowledge of current standards of practice, trends, and developments.
o Participates in relevant workshops, seminars, and continuing education courses to stay current with industry trends, healthcare regulations, and best practices.
o Complete initial and ongoing scribe training, maintain competency in neurodevelopmental documentation, and pursue certification opportunities.
• Finance
o Promotes stewardship of hospital resources while ensuring quality patient care.
o Support accurate documentation to justify medical necessity and coding requirements, reducing billing errors and compliance risks.
o Support accurate documentation to justify medical necessity and proper coding/billing; ensure the record supports CMS coverage, coding, and billing requirements to reduce denials.
o Capture time elements and services rendered (where applicable in behavioral health) to support correct code selection and reduce compliance risk.
o Collaborate with revenue cycle and compliance teams to align documentation with payer policies and organizational standards.
• Performs other duties as assigned.
POSITION QUALIFICATIONS:
EDUCATION:
• High school diploma required; Associate's or Bachelor's degree preferred in health sciences or healthcare related field.
• Completion of formal scribe training aligned with AHDI standards.
EXPERIENCE:
• 1-2 years of scribing or clinical documentation experience preferred, ideally in behavioral health or neurodevelopmental settings.
SKILLS:
• Strong knowledge of medical terminology, behavioral health and neurodevelopmental vocabulary, and ICD 10 concepts including F and Z code documentation nuances.
• Excellent attention to detail, listening, and professional communication skills.
• Proficiency in EHR navigation, role based security, and data integrity; ability to maintain privacy (HIPAA), follow templates, and capture provider MDM accurately.
• Typing speed and accuracy (>60 WPM recommended), active listening, and meticulous attention to detail under fast paced conditions.
• Strong organizational skills.
• Professional communication, empathy, and cultural humility with patients and families with complex behavioral needs.
LICENSURE/CERTIFICATION:
• Certification preferred (CMSP™, CPMS®, or CMSS).
o CMSP™ (Certified Medical Scribe Professional) - American Healthcare Documentation Professionals Group (AHDPG).
o CPMS® (Certified Professional Medical Scribe) - AAPC
o CMSS (Certified Medical Scribe Specialist) - ACMSS/NHA recognized programs.
• HIPAA training and organizational EHR competency sign-off required.
• BLS (Basic Life Support) from American Heart Association//American Red Cross required, must be valid for a minimum of 6 months from date of hire.
Must maintain current certification in good standing during employment with this facility.
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