Medical Scribe

Job Summary

Performs a variety of clerical work but not limited to assist a medical provider with fundamental patient care. Compliance with care management requirements and HEDIS measures in an outpatient examining room setting under the direction of a registered nurse and/or physician.

Essential Duties & Responsibilities

• Shadow physician to document in the EHR System the events in the history and physical exam, and document accurately the Subjective, Objective, Assessment and Plan (SOAP) progress note.

• Guide the clinician in crafting and documenting a detailed disease specific assessment as well as detailed disease specific treatment plan.

• List all relevant symptoms and diagnosis including laboratory test, medication orders, treatment, etc.

• Document all procedures performed by physician.

• Verifies patient information by interviewing patient; recording medical history; confirming purpose of visit.

• Performing post treatment physical tests: taking blood pressure, body temperature; recording patient history summary.

• Inform and review for clinician the appropriate workflows for orders, order sets, referrals, task resolutions, structure data, etc.

• Secures patient information and maintains patient confidence by completing and safeguarding medical records.

• Maintains safe, secure, and healthy work environment by establishing and following standards and procedures, complying with legal regulations.

• Serves and protects the practice by adhering to professional standards, policies and procedures, federal, state, and local requirements.

Additional Duties & Responsibilities

• Maintain and demonstrate an understanding of the team approach to patient care and documentation.

• Pursue continuing education through clinical experiences to enhance skills and knowledge in the promotion of quality documentation.

• Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations.

• Ability to multi-task efficiently and effectively.

• Communicate effectively by phone, in person and in writing.

• Adheres to all policies and procedures, including but not limited to standards for safety, attendance, punctuality, and personal appearance

• Participation on medical reviews, EMR updates and any additional training in regards medical documentation

Supervisory Responsibilities

No Supervisory responsibilities

Critical Results

• S.O.A.P Progress Note Documentation – accurate documentation within the History and Physical exam, as well as the Subjective, Objective, Assessment and Plan (SOAP) >90%

• Review of Clinician Workflow – Informing and reviewing appropriate workflows for orders, order sets, referrals, telephone encounters, actions and structured 90 %

• Quality Training Assurance – Actively participate in Medical Reviews, CMEs, EMR updates and any additional training in regards to medical documentation. >90%

Education & Experience

• Completion of a medical terminology course or one-year medical terminology experience in a clinical setting.

• Recognition of physical exam process and ability to record exam details.

• Computer proficiency and ability to quickly learn new applications.

• Organizational skills with focus on tracking patient care and improving patient flow

• A High School Diploma or equivalent is required and at least two (2) years of experience as a, healthcare student, physician, nursing, physician assistant, healthcare administration, Medical Assistant, Phlebotomist or in additional areas of patient health care in a clinical setting.

• College level education including health or medical related courses

Knowledge, Skills & Proficiencies

Fluency in English and Spanish is required in order to communicate effectively with our patient population.

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Physical Requirements/Working Environment

This position works under usual office conditions. The employee is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk, and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift at least up to 50 lbs.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Physical Requirements/Working Environment

Work will involve some driving/traveling to assigned clinics.

Disclaimer

The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time.

Job Type: Full-time

Benefits:

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

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Application Question(s):

• Have you completed of a medical terminology course?

Experience:

• Medical terminology: 1 year (Preferred)

Language:

• Spanish (Preferred)

Work Location: One location