POSITION SUMMARY:

Under general supervision from the RN Manager/RN Clinic Coordinator, the Medical Scribe is trained in medical documentation and assists a physician or medical provider throughout their shift. The primary goal of a Medical Scribe is to increase the efficiency and productivity of the medical provider they are working with. The Medical Scribe allows the doctor to focus on what is most important, the patient. Medical Scribe duties include performing all clerical and information technology functions for a medical provider in a clinic setting. This includes primary responsibility of the operation of the electronic health record system. You also must be able to anticipate physician needs to facilitate the flow of clinic. Medical Scribes must be 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. You must be adaptable and versatile since you will be responsible for many tasks.

ESSENTIAL JOB FUNCTIONS:

Essential functions, as defined under the Americans with Disabilities Act, may include any of the following tasks, knowledge, skills, and other characteristics. The list that follows is not intended as a comprehensive list, but rather to provide a representative summary of the major duties and responsibilities. Incumbent(s) may not be required to perform all duties listed, and may be required to perform additional, position-specific tasks.

• Accompany medical provider into the patient examination room in order to transcribe a history and physical exam, and document accurately the medical provider’s encounter with the patient and others present.
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the medical provider.
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
• Document any procedures performed by the medical provider.
• Dictation/faxing/phone calls and clerical tasks. Medical Scribes may be asked to prepare referral letters as directed by the medical provider, via dictation or summary of the medical record. Medical Scribes also ensure that letters with all copies of pertinent reports or tests attached are processed or routed for transmission, mailing or faxing in accordance with established clinic workflow and timeliness expectations to all relevant medical providers involved in a patient’s care.. You may be asked to research contact information for referring providers, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
• Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a medical provider. Medical Scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the medical provider are recorded accurately in the medical record. Alert medical provider when chart is incomplete. Medical Scribes 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.
• 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. Medical Scribes proofread and edit all the medical provider’s medical documents generated by the scribe for accuracy, spelling, punctuation, and grammar.
• Other duties as assigned.

EDUCATION, EXPERIENCE, CERTIFICATIONS, AND LICENSES:

• High School Diploma or equivalent.
• Current CPR certification or able to obtain one within 60 days.
• Able to work collaboratively with multiple health professionals in a busy and complex environment using tact, diplomacy, and discipline.
• Strong charting/documentation skills utilizing advanced computer skills.
• Commitment to excellence, high standards, and strong interpersonal skills.
• Excellent written and oral communication skills, strong organizational problem-solving and analytical skills.
• Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm as an innovative team player.
• Acute attention to detail.

Indian Preference: Preference in filling vacancies will be given to qualified Indian candidates, in accordance with the Indian Preference Act (Title 25, U.S. Code, Section 472 and 473). In other than the above, NVIHis an equal opportunity, affirmative action employer, and does not discriminate in employment decisions based on race, color, religion, gender, national origin, age disability, or sexual orientation
Job Benefits:

• Medical/Dental/Vision Insurance
• Life insurance and Long Term disability
• Generous PTO Accrual
• 14 paid holidays
• 401k with employer match