Medical Scribe / Medical Administrative Assistant

This is a fully remote position, open to applicants in South Africa.

📋 Description

• Accompany physicians during patient consultations and examinations to document clinical interactions in real-time.

• Record the patient's primary complaint, history of present illness, pertinent medical history, physical examination observations, and assessment and treatment plan.

• Precisely capture clinical data while attentively listening to dialogues between healthcare providers and patients.

• Adjust to various physicians' documentation styles and workflows.

• Review patient medical records prior to consultations.

• Verify medication lists, previous clinical notes, pending lab results, and imaging reports.

• Ensure pertinent information is accessible to the physician before the appointment.

• Identify missing information or outstanding results that may necessitate follow-up.

• Enter laboratory, diagnostic imaging, and other medical orders as directed by the physician and in line with approved procedures.

• Assist with entering referrals and prescription details as authorized.

• Confirm all entries are accurate and highlight discrepancies or missing information for the provider's review.

• Review and organize clinical notes after patient consultations.

• Assist with visit summaries and supporting documentation.

• Recognize incomplete sections and flag records needing physician review, correction, or signature.

• Help ensure patient charts are completed accurately and within required timeframes.

• Guarantee documentation captures the clinical details necessary to support accurate medical coding and billing.

• Adhere to applicable patient privacy, confidentiality, and healthcare documentation standards.

• Maintain the accuracy and integrity of electronic medical records.

• Manage sensitive patient information responsibly and in compliance with relevant privacy regulations, including HIPAA where applicable.

• Aid in patient flow by keeping documentation updated and assisting in reducing administrative backlogs.

• Efficiently manage multiple documentation tasks and outstanding items.

• Communicate with physicians and relevant clinical staff regarding incomplete records or documentation inconsistencies.

• Maintain organized records and adhere to established clinical workflows.

⛳️ Requirements

• Previous experience as a Medical Scribe or in a closely related clinical documentation role is preferred.

• Strong understanding of medical terminology, anatomy, physiology, common diagnoses, and clinical abbreviations.

• Experience with electronic health record (EHR) systems such as Epic, Cerner, Allscripts, or similar platforms.

• Exceptional typing speed and accuracy; a typing speed of 60–80 words per minute is preferred.

• Strong written English skills with the ability to create clear, accurate clinical documentation.

• Excellent listening skills and the capability to capture relevant clinical details during live consultations.

• Strong attention to detail and the ability to recognize missing or inconsistent information.

• Understanding of patient confidentiality and healthcare privacy protocols.

• Ability to operate efficiently in a fast-paced healthcare environment.

• Capability to accurately capture patient information and physician instructions.

• Familiarity with common clinical terms, diagnoses, medications, and procedures.

• Ability to distinguish significant clinical information from general conversation.

• Ability to complete documentation promptly while managing multiple tasks.

• Capacity to adapt to different physician preferences, specialties, and documentation workflows.

• Ability to handle sensitive medical information in a professional and secure manner.

• Ability to work collaboratively with physicians and clinical teams to address documentation gaps.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional growth and development.

• Supportive work environment with a focus on teamwork.

• Flexible work hours to maintain a healthy work-life balance.