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TYPE OF WORK
Full Time
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SALARY
$6-7/hour
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HOURS PER WEEK
40
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DATE UPDATED
Jan 25, 2026
ROLE SUMMARY
You will assist the provider by documenting patient encounters accurately and efficiently. You must be able to capture a complete history, document a focused physical exam (as directed by the provider), write a clear assessment, and help draft a coherent treatment plan using correct medical terminology. You should be comfortable with ICD-10 concepts and basic coding awareness (CPT familiarity is a plus).
KEY RESPONSIBILITIES
Clinical Documentation / Scribing
- Document patient encounters using structured templates (HPI, ROS, PMH/PSH, meds/allergies, exam, assessment, plan)
- Obtain and document a clear patient history (on the call or via structured intake workflow)
- Document focused physical exam findings as directed by the provider (do not invent findings)
- Draft an organized assessment and treatment plan that reflects the provider’s medical decision-making
- Ensure documentation supports medical necessity (failed conservative care, functional limitation, duration, imaging correlation, objective findings, etc.)
- Maintain high accuracy and consistency with pain management / spine documentation standards
Coding Awareness (Basic)
- Be familiar with ICD-10 diagnosis concepts relevant to pain/spine conditions
- Basic awareness of CPT and procedure documentation requirements (final coding and sign-off remain with the provider/clinic protocols)
- Ability to identify documentation gaps that could affect billing, coding, or medical necessity and flag them to the provider
Administrative Support
- Receive and organize incoming documents (referrals, imaging, PT notes, prior records)
- Upload/attach documents appropriately in the chart (per clinic workflow)
- Send and request documents as directed (records requests, referral packets, follow-up requests)
- Assist with template creation and note optimization for efficiency and consistency
QUALIFICATIONS (REQUIRED)
- Bachelor’s degree in a healthcare-related field (examples: nursing/allied health/biology/rehab sciences). Advanced clinical training is strongly preferred (e.g., MD, PT, RN, DPT, etc.)
- Fluent English (spoken and written) with professional patient-facing communication
- Strong medical terminology and anatomy knowledge, especially musculoskeletal/spine
- Must be responsible, punctual, and able to work independently with minimal supervision
- Reliable high-speed internet + backup connection, quiet private workspace, and professional headset
EXPERIENCE (PREFERRED)
- 1+ year experience in U.S. clinical documentation/scribing (preferred)
- 1+ year experience in pain management, PM&R, ortho-spine, neurology, or similar specialty documentation (preferred)
- Familiarity with eClinicalWorks (eCW) is preferred (other U.S. EHR experience is acceptable if you learn quickly)
- Comfortable learning and following clinic-specific templates and workflows quickly
WORK STYLE EXPECTATIONS
- Extremely detail-oriented and accuracy-focused
- Able to ask clarifying questions when appropriate and communicate issues promptly
- Able to manage multiple priorities, meet deadlines, and maintain consistent documentation quality
HOW TO APPLY (IMPORTANT)
To be considered, please follow these instructions exactly:
1) Submit your resume/CV
2) In the FIRST LINE of your application message, type: GENESIS SCRIBE
3) Answer the questions below:
- What specialties have you scribed/documented for (pain, PM&R, ortho, neuro, etc.)?
- Which EHR/EMR systems have you used (eCW preferred)?
- What is your typing speed (WPM) and your internet speed? (Include a screenshot if available)
- Describe your experience documenting: history, physical exam, assessment, and treatment plan
- Provide 2–3 examples of ICD-10 diagnoses you commonly used in spine/pain documentation (no patient identifiers)
Applicants who do not follow the application instructions will not be considered.
