Job Description

Default Work Shift:

Day (United States of America)

Hours:

40

Salary range:

$19.72 - $29.95

Schedule:

Full Time

Shift Hours:

8 Hour employee

Department:

EDOC Pain Clinic (Hope Square)

Job Objective:

Responsible for providing in person real-time documentation assistance for clinicians. The purpose of the Scribe is to free the clinician from enough data entry to allow focus on other aspects of patient care. Documents on behalf of the provider while under the supervision of the provider but will not otherwise participate in the medical care of the patient. Education:
Required: Associate's Degree in healthcare related field or two (2) years of experience in lieu of degree
Licensure/Certification:
Preferred: Medical Scribe Certification
Experience:
Required: Two (2) years of experience in Electronic Health Records (EHR) or in a licensed/certified patient care position or Associate's Degree in Healthcare field in lieu of experience Reports To: Practice Manager Supervises: N/A Ages of Patients: Adolescent, Adult, Geriatric Blood Borne Pathogens: Minimal/ Moderate Potential

Skills, Knowledge, Abilities:

Ability to type a minimum of 60 WPM, Computer literate in usage of (Word, Excel, Outlook, etc), Excellent customer service, communication, and verbal and written skills and the ability to deal with difficult and stressful situations in a calm and professional manner, Knowledge of medical scribing and workflow, Knowledge of medical terminology and human anatomy a plus, Proficient with computer systems, including Electronic Health Records (EHR), Proven organizational skills, including attention to detail, able to prioritize multiple tasks, and follow processes, Understanding of medical note content, and medical billing and coding

Essential Responsibilities

1. Demonstrates compliance with Code of Conduct and compliance policies and takes action to resolve compliance questions or concerns, and reports suspected violations.
2. Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician, including but not limited to: Patient medical history and physical exam, Procedures and treatments performed by healthcare professionals
3. Completes documentation accurately as per policy and practice.
4. Medical scribes must meet all Eisenhower standards regarding information management, HIPPA, confidentiality and patient rights.
5. Prepares and assembles medical record documentation/charts for physician(s).
6. Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.
7. Ensures medical record compliance by self-documentation attestation.
8. Updates patient history, physical exam, and other pertinent health information in the patient's record.
9. Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
10. Monitors the duration of basic lab results and screening procedures.
11. Complies with hospital and medical facility policies, including those relating to Joint Commission.
12. Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
13. Performs other duties as assigned.