We are seeking a Medical Documentation (Scribe) Specialist with coding knowledge who is an exceptional documenter. This individual will support an AI-assisted clinical documentation workflow by reviewing, editing, supplementing, and finalizing AI-generated provider notes; accurately entering and organizing completed documentation in the EMR; and preparing each encounter for accurate, compliant billing.
This role serves as an important bridge between the provider, clinical documentation, coding, and billing teams. The ideal candidate understands ICD-10-CM and CPT coding principles, recognizes when services such as injections, X-rays, imaging, procedures, and supplies require additional documentation, and confirms that every service being sent to billing is supported by the medical record. Orthopedic experience and familiarity with AdvancedMD are preferred, but training may be provided to the right candidate.
Key Responsibilities
- Review, edit, and finalize clinical notes generated by an AI scribe platform for accuracy, clarity, completeness, and consistency.
- Transcribe, supplement, or restructure AI-generated content when needed to accurately reflect the provider encounter.
- Enter finalized documentation into the EMR and ensure information is placed in the correct sections, fields, and templates.
- Navigate multiple templates, screens, and documentation workflows simultaneously while maintaining accuracy and productivity.
- Apply working knowledge of ICD-10-CM and CPT terminology to identify documentation requirements and potential coding or billing gaps.
- Confirm that diagnoses, procedures, supplies, and ancillary services submitted for billing are supported by the provider note.
- Review documentation for additional services such as injections, medications, X-rays, diagnostic imaging, procedures, durable medical equipment, and other billable services.
- Verify that documentation includes required elements such as medical necessity, laterality, anatomical site, dosage, route, units, imaging findings, procedure details, and treatment plan when applicable.
- Identify missing, conflicting, or unclear information and route questions to the provider or appropriate team member before billing.
- Learn each provider's documentation style, clinical preferences, templates, terminology, and workflow, then adapt efficiently to those expectations.
- Ensure the final note accurately represents the provider's intent without independently altering clinical meaning or assigning unsupported diagnoses or services.
- Collaborate with providers, coders, billers, and revenue cycle staff to resolve documentation issues that may delay or prevent clean claim submission.
- Maintain consistent formatting, grammar, spelling, medical terminology, and professional documentation standards.
- Meet established turnaround-time, quality, and productivity expectations in a remote work environment.
- Maintain strict confidentiality and comply with HIPAA, organizational policies, and all applicable documentation standards.
Qualifications
- Current professional coding certification, such as CPC, CCS, CCA, or an equivalent recognized credential.
- Practical coding experience with a working understanding of ICD-10-CM diagnosis coding and CPT procedure coding; extensive coding experience is not required.
- Previous experience in medical transcription, clinical documentation review, medical scribing, coding support, or a closely related role.
- Strong knowledge of medical terminology, anatomy, physiology, and common clinical documentation standards.
- Ability to determine whether the documentation supports services being prepared for billing and to recognize when clarification is needed.
- Excellent listening, typing, editing, proofreading, and written communication skills.
- Exceptional attention to detail and ability to identify subtle inconsistencies, omissions, or unsupported services.
- Ability to work across multiple templates and applications while maintaining accuracy and organization.
- Ability to learn and adapt to individual provider styles, preferences, and workflow expectations.
- Ability to work independently, manage priorities, and meet deadlines in a remote environment.
Perks
- Permanent Work From Home
- Leave Credits
- Monetary Allowance
- Annual Bonus
- Weekly Paychecks
- Fixed Weekends Off
- Thriving Company Culture with Complete Autonomy
- Exclusive Specialized Training Programs
- Unlock Your Potential with a Highly Competitive Salary
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Who are we
BizForce is one of the fastest-growing global outsourcing companies in the world, founded in the US in Tucson, Arizona and is now operational in PH!
Our Commitment to delivering high-quality results for our clients and the only way to do that is ensuring a rewarding, respectful and productive experience for our employees. We hold the same values for both our customers and our employees.
