Part time Scribe (Potential for Fulltime with Medical Assistant responsibilties)

Position Summary/Scope of Responsibility

The Centers for Advanced Orthopaedics LLC (CAO) is one of the nation’s largest Orthopaedics practices, owned and operated by physicians, with over 60 locations across Maryland, Northern Virginia, and the District of Columbia. With approximately 2,000 employees, working in 28 Divisions, CAO is a growing business with revenues of approximately $250 Million. CAO is committed to be the Orthopaedics provider of choice for our patients; partner of choice for payors and health systems; and employer of choice by attracting and retaining a talented workforce.

The Scribe prepares and assembles medical record documents/charts for physicians and prepares and sends all documentation to physicians for review and approval. The Scribe ensures medical record compliance and complies with hospital and medical facility policies. Responsible for updating patient history, physical exams, and other pertinent health information and monitoring the duration of basic lab results and screening procedures.

There is potential for this to be a full time role with Medical Assistant duties in addition to the Scribe responsibilities.

Scribe duties include, but are not limited to:

• Prepares and assembles medical record documentation/charts for physician(s).
• Accompanies physician(s) during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
• Ensures medical record compliance by self-documentation attestation.
• Updates patient history, physical exam, and other pertinent health information.
• Prepares and sends all documentation to physician(s) for review and approval via authentication of detailed data entry and facility-specific procedures.
• Monitors and documents the duration of basic lab results, radiographic studies, and screening procedures as dictated by the physician(s).
• Complies with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.
• Refers all requests related to patient care to the responsible physician or nursing staff.
• Performs other duties as assigned.

Potential Medical Assistant (For full time role only) duties include, but are not limited to:

• Represents CAO and the Practice in a professional and patient-focused manner, with an emphasis on service excellence.
• Shows patients to examination rooms, procedure rooms or operative rooms and prepares them for the physician.
• Records patients' medical history, medications, allergies, vital statistics, and information such as test results in medical records.
• Ensure proper consent forms are obtained prior to preparing a patient for treatment.
• Prepare and administer medications as directed by a physician following safety protocol of right dose, right patient, right route, right drug and noting expiration date.
• Explain treatment procedures, medications, diets, wound care instructions and physicians' instructions to patients.
• Help physicians examine and treat patients, handing them instruments and materials or performing such tasks as giving injections and removing sutures.
• Under Provider direction, authorize drug refills and provide prescription information to pharmacies.
• Prepare treatment rooms for patient examinations, keeping the rooms neat and clean.
• Keeps exam room supplies stocked, audits and discards expired medications, maintains instruments, and prepares sterilization as required.
• Maintains all logs and required checks (e.g., refrigerator temperature, expired medications, autoclave, etc.).
• Keeps equipment operating by following operating instructions, troubleshooting breakdowns, maintaining supplies, performing preventive maintenance, and notifying manager when unable to resolve matters.
• Adheres to all CAO and Practice professional standards, policies and procedures, and federal, state, and local requirements. These include but are not limited to safety, attendance, punctuality, personal appearance, and conduct.
• Secures patient information and maintains patient confidence by completing and safeguarding medical records, completing diagnostic coding, and keeping patient information confidential.
• Maintains an effective and collaborative working relationship with patients, medical staff, coworkers, and the public.
• Assists providers with office procedures.
• Takes telephone messages and provides feedback and answers to patient/physician/surgery center/pharmacy calls.
• Performs other duties as assigned.

Required Education & Experience

• High School Diploma or Equivalent.
• Skilled in operating various medical record software and hardware, word-processing, and database software programs.
• Medical Assistant Certification (For full time role only.)
• CPR for Healthcare Providers certification preferred. (For full time role only.)
• One year of experience as a Medical Assistant in a busy physician’s office, or equivalent combination of certification and experience, preferred. (For full time role only.)
• Experience and proficiency working with computers and electronic medical records.
• Knowledge of medical terminology and human anatomy preferred.
• Minimum of 60 WPM preferred.

Competencies/Required Skills & Abilities

• Strong Interpersonal Skills - Ability to develop relationships and collaborate and influence in a decentralized organization.
• Strong skills in record keeping and typing/word processing at 60 WPM.
• Demonstrated ability to organize, prioritize, and manage multiple tasks in a dynamic environment with a proven track record of results.
• Strong oral and written communication skills with excellent self-discipline and patience.
• Able to work independently.
• Excellent time management, organization, and administrative support skills.
• Must be able to read, write, speak, understand, and communicate in the English language.

Physical Demands

• Must be able to sit for long periods of time and lift up to 50 pounds.
• Must be able to use appropriate body mechanics when making necessary transfers and helping patients with exercises.
• Requires frequent bending, reaching, repetitive hand movements, standing, walking, squatting, and sitting.
• Some heavy lifting, pushing, and pulling exerted regularly throughout a standard work shift.
• Adequate hearing to perform duties in person and over telephone.
• Requires hand-eye coordination and manual dexterity needed to operate a keyboard, medical equipment, fax machine, scanner, photocopier, and telephone.
• Must be able to communicate clearly to patients in person and over the telephone.
• Visual acuity adequate to perform job duties, including reading materials from printed sources and computer screens.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.