Description

The Medical Scribe performs all clerical and information technology functions for a physician in a clinic setting. The primary goal is to increase the efficiency and the productivity of the physician they are working for. This includes primary responsibility of the operation of the electronic health records. The Medical Scribe must be able anticipate physician needs to facilitate the flow of clinic, while being discreet, tactful, and modest in performance of duties so as not to distract medical staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. 

Requirements

1. Accomplishes Medical Scribe human resource strategies by determining accountabilities; communicating and enforcing values, policies, and procedures; implementing recruitment, selection, orientation, training, appraising and coaching programs; approving timesheets for payroll purposes.
2. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
   1. Patient medical history and physical exam;
   2. Procedures and treatments performed by healthcare providers, including physician and physician assistants;
   3. Patient education and explanations of risks and benefits;
   4. Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.

3. May research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.

4. May spot mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors. All addenda must be signed off by a physician. Must ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete. Must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.

5. Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. Assist in developing and maintaining systems to track patient follow up and compliance.

6. Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures.

7. Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

8. Other duties as assigned.

9. All employees have a responsibility to comply with our organization’s policies and procedures, code of conduct and mission, values & vision.

Education: High school diploma or equivalent. Some college preferred.

Experience: Minimum one year of recent experience working in a medical facility as a medical scribe or medical assistant and/or documented evidence of externship completed in a medical office. 

Performance Requirements:

Knowledge:

1. Knowledge of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe. May translate medical abbreviations into their expanded forms.
2. Knowledge of Electronic Medical Record software.
3. Knowledge of and compliance with HIPAA confidentiality standards when accessing or communicating patient information.

Skills:

1. Skill at listening to complex medical information and summarizing in a clear, complete, and concise fashion. Must accurately enter data into a database, search for information, send and receive email and attachments.
2. Skill at English composition to generate professional, polished writing at a high rate of production. Excellent spelling, punctuation, grammar, and oral communication skills.

Abilities:

1. Ability to type 40 WPM consistently and accurately.
2. Ability to apply common sense understanding to instructions furnished in written or oral form. 
3. Ability to apply logic and draw conclusions based on knowledge. 
4. Ability to refer to reference materials to solve problems.
5. Ability to project a pleasant and professional image.

Equipment Operated: Standard medical exam/office equipment including computerized health information management system for medical records. 

Work Environment: Combination of medical office and exam/procedure room settings. Well-lighted, well-ventilated, adequate space.

Physical Requirements: While performing the duties of this Job, a Medical Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, handle, or feel; reach with hands and arms and talk or hear. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The Medical Scribe must regularly lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

COVID-19 considerations: We follow CDC recommendations for a safe working environment. Masks, hand sanitizer and social distancing.

COVID-19 vaccination required to be considered for this position

Company Paid Benefits

Basic Life/AD&D –Guardian

16 days of PTO per year

7-7.5 paid holidays per year

EAP

401(k) Safe Harbor Contribution

Benefit Options Requiring Employee Contributions

· Medical

· HSA and FSA

· Dental

· Vision

· Short-Term Disability

· Voluntary Life and AD&D

· Flex Spending Accounts

· General Purpose Healthcare FSA

· Optional Protection Benefits (Accident, Hospital Indemnity, Cancer Care and Critical Illness Insurance)

· 401K