Medical Scribe / Clinical Documentation Assistant

About Atlas Surgery Center

Atlas Surgery Center is a state-of-the-art ambulatory surgery center providing specialized surgical care for patients with neurologic, endovascular, pain management, and Gamma Knife radiosurgery needs. Atlas is committed to delivering safe, high-quality care in a focused surgical environment that supports patient safety, clinical excellence, and a positive experience for patients, providers, staff, and learners.

Position Summary

Atlas Surgery Center is seeking a full-time Medical Scribe / Clinical Documentation Assistant with prior experience working in a medical or clinical setting to support our providers and clinical operations team.

This position is best suited for someone who already has a strong working knowledge of medical terminology, clinical documentation, and healthcare workflows. Relevant backgrounds may include experience as a medical scribe, medical assistant, clinical assistant, patient care technician, nursing assistant, medical office assistant, or another healthcare support role involving patient charts and clinical documentation.

The primary responsibility of this position is to serve as a medical scribe during assigned provider and procedure days by documenting patient encounters, provider assessments, procedural information, treatment plans, and other relevant clinical information within the electronic medical record (EMR) in real time.

When not actively scribing, the Clinical Documentation Assistant will support chart preparation, documentation review, EMR maintenance, medical record organization, chart audits, and other clinical administrative workflows.

This is not an entry-level general administrative or data-entry position. Prior experience working in a healthcare environment and familiarity with medical terminology and patient documentation are required.

Key Responsibilities

Key responsibilities include, but are not limited to:

• Accurately document provider-patient encounters, assessments, treatment plans, procedural information, and related clinical documentation within the EMR.
• Scribe in real time during provider clinic and procedure days while maintaining accuracy in a fast-paced clinical environment.
• Assist providers with timely completion of documentation and chart closure.
• Prepare and organize patient charts prior to visits and procedures.
• Review medical records for missing documentation, signatures, orders, consents, results, or other required information.
• Identify documentation deficiencies and communicate them to the appropriate provider, clinical staff member, or administrative team member.
• Enter, update, scan, and organize information within the electronic medical record.
• Assist with obtaining laboratory results, imaging reports, medical records, and other information required for complete patient charts.
• Support efficient provider workflow and patient-care operations.
• Assist with chart audits, documentation review, quality activities, and medical-record compliance.
• Maintain accurate and organized patient records while protecting patient confidentiality.
• Follow HIPAA requirements, facility policies, and applicable regulatory requirements.
• Communicate effectively with physicians, nurses, clinical staff, and administrative personnel.
• Provide additional clinical or administrative support within the individual's training and demonstrated competency.
• Participate in staff meetings, training, and workflow-improvement initiatives.
• Perform additional duties as assigned.

Required Qualifications

• High school diploma or equivalent.
• Prior experience working in a medical office, physician practice, outpatient clinic, ambulatory surgery center, hospital, or other healthcare setting.
• Experience working with patient medical records, clinical documentation, or an electronic medical record system.
• Strong working knowledge of medical terminology.
• Ability to understand and accurately document clinical information, including assessments, procedures, diagnoses, treatment plans, and follow-up instructions.
• Strong computer skills and ability to learn and navigate electronic medical record systems efficiently.
• Strong typing, written communication, and documentation skills.
• Excellent attention to detail and ability to identify missing or incomplete information.
• Ability to document accurately while listening to provider-patient conversations in real time.
• Ability to work effectively in a fast-paced clinical environment with changing priorities.
• Strong organization and time-management skills.
• Ability to communicate professionally with physicians, clinical staff, administrative personnel, and patients.
• Ability to maintain patient confidentiality and comply with HIPAA requirements.
• Ability to work collaboratively as part of a multidisciplinary healthcare team.

Preferred Qualifications

Preference may be given to candidates with one or more of the following:

• Previous medical scribe experience.
• Medical assistant, clinical assistant, patient care technician, nursing assistant, or similar healthcare experience.
• Experience supporting physicians or advanced practice providers.
• Experience preparing or reviewing charts for clinic visits, procedures, or surgery.
• Experience with clinical documentation, chart review, medical records, or documentation auditing.
• Experience working in an outpatient specialty practice or ambulatory surgery center.
• Familiarity with procedural or surgical terminology.
• Knowledge of anatomy, physiology, and common medical abbreviations.
• Medical Assistant certification.
• Medical Scribe certification.
• Current Basic Life Support certification.

Schedule / Work Hours

This is a full-time, in-person position.

Shifts are generally scheduled during regular business hours but may vary based on provider schedules, procedure days, patient-care needs, staffing, and facility operations.

Candidates must be able to work a flexible daytime schedule based on clinical and provider needs.

Compensation

The expected compensation range for this position is $18.00–$23.00 per hour.

Actual compensation will be determined based on relevant healthcare experience, education, qualifications, certifications, skills, and internal equity.

This range represents Atlas Surgery Center's good-faith estimate of the expected compensation for this position at the time of posting, in accordance with New York State pay transparency requirements.

Benefits

Benefits eligibility may vary based on employment status, scheduled hours, and applicable plan terms. Eligible employees may receive:

• Medical, dental, and vision insurance with employer contributions
• Benefits effective the first of the month following date of hire, if eligible
• Paid time off, if eligible
• Paid sick leave in accordance with New York State law
• Paid holidays, if eligible
• 401(k) plan with employer match eligibility, subject to plan terms

Physical Requirements and Work Environment

Work is performed primarily in an ambulatory surgery center and clinical office environment, including provider work areas, clinical spaces, and related administrative areas.

This position requires frequent sitting, standing, walking, bending, reaching, and computer use. The role requires prolonged periods of computer and EMR documentation work, close visual attention, and repetitive hand movement for typing and data entry.

The employee must be able to communicate effectively with providers, clinical staff, administrative staff, and other members of the care team.

The employee may occasionally lift, carry, or move office supplies, charts, medical records, or related materials. This role may involve exposure to patient-care areas, confidential patient information, clinical workflows, medical equipment, and standard healthcare-environment conditions. Personal protective equipment must be worn as required by facility policy.

Equal Employment Opportunity Statement

Atlas Surgery Center is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all applicants and employees without regard to race, color, creed, religion, sex, age, national origin, citizenship or immigration status, disability, pregnancy or related condition, sexual orientation, gender identity or expression, marital status, familial status, military or veteran status, status as a victim of domestic violence, reproductive health decision-making, arrest or conviction record to the extent protected by law, or any other characteristic protected by applicable federal, state, or local law.

Pay: $18.00 - $23.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Retirement plan
• Vision insurance

Application Question(s):

• Do you have a high school diploma or equivalent?
• Please describe your experience working in a medical or clinical setting.
• What electronic medical record (EMR) systems have you used, and how did you use them in your role?
• Please describe your experience with medical terminology, patient charts, or clinical documentation.
• Have you documented provider-patient encounters, assessments, procedures, or treatment plans? If yes, please briefly describe your experience.
• How many years of experience do you have working in a medical or clinical setting?

Work Location: In person

Salary : $18 - $23