Medical Scribe/Clinical Documentation Special
About the position The Medical Scribe/Clinical Documentation Specialist supports behavioral health providers by accurately documenting patient encounters, maintaining clinical records, and ensuring timely completion of documentation in compliance with organizational, state, and federal guidelines. This role improves provider efficiency and supports quality patient care in a nonprofit community mental health setting.
Responsibilities
- Accurately enter histories, assessments, treatment plans, diagnoses, and progress notes into the electronic health record (EHR).
- Review documentation for accuracy, completeness, and compliance with HIPAA and agency standards.
- Track unsigned notes, missing documentation, and authorization requirements.
- Maintain confidentiality of all individuals served and organizational information.
- Communicate professionally with psychiatrists, therapists, case managers, nurses, and administrative staff.
- Participate in staff meetings, training, and quality improvement activities.
- Ensure documentation meets Medicaid, Medicare, and accreditation standards.
Requirements
- High school diploma or GED required
- Strong typing, grammar, proofreading, and organizational skills.
- Ability to work in a fast-paced clinical environment while maintaining accuracy and professionalism.
Nice-to-haves
- associate or bachelor’s degree preferred.
- Experience in medical scribing, behavioral health, medical records, or clinical documentation preferred.
- Knowledge of behavioral health terminology, psychiatric diagnoses, and treatment documentation preferred.
- Familiarity with EHR systems such as Epic, Credible, eClinicalWorks, or similar platforms.
- Bilingual English/Spanish preferred in Miami-Dade settings.
- Understanding of HIPAA regulations and patient confidentiality.
- Knowledge of ICD-10 and behavioral health documentation standards.
- Strong attention to detail and time management.
- Ability to maintain professional communication with diverse populations.