Medical Assistant Scribe

Job Description

Job Description

The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on what is most important, the patient. 

A summary of Medical Scribes duties includes performing all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of operating the electronic health records and electronic dictation system. You also must be able to anticipate physician needs to facilitate the flow of clinic. This is an on-site position. Medical Assistants receive clinical supervision and direction solely from licensed providers. The Clinic Operation Manager provides administrative and operational oversight only.

What you will do: 

• Accurately and thoroughly document 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, including nurses and physician assistants.
• Patient education and explanations of risks and benefits.
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
• Prepare referral letters as directed by the physician.
• Dictation/faxing/phone calls and clerical tasks.  Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record.  Medical Scribe also ensures that reports or tests attached.  You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, manage the providers schedule and other clerical tasks as assigned.
• Medical Scribes also 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.  Medical Scribes ensure that all clinical data, lab or other rest results, the interpretation of the results by the physician are recorded accurately in the medical record.  Alert physician 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.
• Medical Scribes collects, organizes, and catalogs date for physician quality reporting system and other quality improvement efforts and format for submission.  You will assist in developing and maintaining systems to track patient follow-up and compliance.
• Medical Scribes proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar and often follow the provider to various offices.
• Performs additional responsibilities as appropriate to the role and scope of practice.

Qualifications:

• High School Diploma or GED required
• Completion of a Medical Assistant course from an accredited/recognized school. 
• Current BCLS with AED certificates.
• Experience in a medical clinic, hospital or SNF setting: 1 year
• Ability to read, write, and comprehend medical documentation. 
• Excellent computer skills to include Microsoft Excel and Microsoft Word.
• Must be comfortable using Electronic Medical Record software (we will train the successful candidate to use our software). 
• Ability to effectively present information, both verbal and written. 
• Excellent interpersonal skills required to communicate effectively and professionally with patients, medical professionals, and co-workers. 
• Knowledge of all state and federal regulations pertaining to confidentiality pursuant to HIPAA, treatment, and safety guidelines.