Clinical Scribe II

The Remote Clinical Scribe is responsible for providing accurate documentation and summarization of the ocular examination and recommendations while maintaining patient flow and communication regarding appointment status. Must be in IL, MI, OH, IA, WA, PA or GA.

What You Will Be Working On:

• Listen to the encounter in real-time via a HIPAA-compliant audio or video connection (e.g., Zoom for Healthcare, EMR-integrated audio).
• Correctly summarize and document what the physician verbalizes during an examination, including, but not limited to, proper charting of the examination.
• Document the encounter within the EMR under the provider's supervision, including:
• Chief Complaint & HPI
• Review of Systems
• Exam findings (as dictated by provider or read from tech notes)
• Assessment & Plan
• Procedure documentation (e.g., injections, lasers)
• Accurately bring Team Lead/Manager's attention to chart errors according to remote practice protocols.
• Prepare accurate eyeglass or contact lens prescriptions and/or medication prescriptions per protocol, prior to the physician's completion of the examination, when applicable.
• Complete the superbill in the EMR and Route Slip, and relay the next steps to the in-office support staff.
• Collect all pertinent information for upcoming procedures/surgeries, as protocol dictates.

Clinical Workflow & Compliance

• Know required components of examination for appropriate CPT coding to ensure all elements are accurately completed and documented accordingly.
• Understand Medicare and other common insurance requirements for quality reporting to help practice comply with payer requirements.
• Alert the physician to patient-related forms that need completion.
• Send appropriate forms, labs, and/or testing to the primary care physician and/or specialists, per protocol.
• Remain logged into the secure, live audio/video connection with the physician during the assigned clinic session, limiting time away, as documentation may be missed.
• Does not independently interpret imaging, enter orders, or communicate with patients.

Remote Operations & Communication

• Work in a secure, private environment with no external recording, screenshots, or downloads of Protected Health Information (PHI).
• Facilitate real-time communication between the physician and other in-office staff members (via secure internal messaging/chat) to minimize clinic flow disruptions and coordinate patient needs.
• Notify the physician of changes to the daily schedule, especially emergencies, via secure internal communication.
• Learn the personality and preferences of each physician, recognizing differences and abiding by them.
• Consistently and pro-actively perform any necessary documentation or administrative duties during any lull in clinic, making productive, wise use of time.
• Perform other administrative and documentation tasks, as required.

What Will Make You Awesome:

• Exceptional verbal and written communication skills in order to establish excellent rapport with our patients.
• Excellent interpersonal and customer service skills.
• Ability to function independently and well in a high-paced and at times stressful environment.
• Ability to prioritize and handle a variety of tasks with proven flexibility.

What You Know:

To be successful in this role you will have the following experience or knowledge:

• High school diploma or equivalent.
• Two years' experience in an ophthalmology setting is preferred.
• Certification preferred: Note: Valid proof of current certification necessary, if certified.
• OSC (Ophthalmic Scribe Certified)
• COA (Certified Ophthalmic Assistant)
• COT (Certified Ophthalmic Technician)
• COMT (Certified Ophthalmic Medical Technologist)
• Excellent spelling ability.

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance