Medical Scribe

PRIMARY FUNCTION

Provides documentation assistance to a licensed practitioner to increase efficiency and productivity throughout their shift. This role is critical in helping to close care gaps, streamline documentation, and ensure accurate coding and follow-up planning for patients. The ideal candidate will thrive in a fast-paced environment, possess strong knowledge of medical terminology, and be passionate about improving patient outcomes in a VBC setting.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This list may not include all of the duties that may be assigned.

1. Prepare for patient visit by reviewing patient records prior to it (reason of the visit, previous test results, medical history, care gaps).
2. Review patient records and leverage EHR tools to identify and flag care gaps (e.g., screenings, vaccinations, chronic disease monitoring). Collaborate with providers to ensure VBC quality metrics are addressed during each visit.
3. Alert provider when patient is ready to be seen.
4. Facilitates communication between the provider and patient as interpreter, as needed.
5. Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, ensure care and ensure accurate risk adjustment and coding.
6. Accurately document all provider-stated diagnoses during patient encounters, ensuring appropriate ICD-10 coding.
7. Assist in entering and updating the clinical decision-making process and treatment plan as directed by the provider.
8. Enter prescribed medications and reconcile current medications in the EHR as instructed by the provider.
9. Utilize computerized provider order entry to input lab, imaging, and diagnostic test orders as directed by the provider.
10. Initiate referrals to specialists or external services per provider instruction and ensure accurate documentation of referral reasons and urgency.
11. Schedule follow-up appointments based on provider recommendations to ensure continuity of care and timely closure of care gaps
12. Change visit status appropriately in the EHR to support efficient clinic workflows and patient throughput.
13. Support onboarding and training of newly hired medical scribes by sharing best practices, demonstrating workflows, and offering mentorship as needed.
14. Assist with EHR inbox management, including reviewing and processing e-refill requests, uploading external documents, documenting lab and diagnostic results, and managing patient messages and phone calls in coordination with clinical staff.
15. Perform additional administrative or clinical documentation support tasks on an as-needed (PRN) basis to ensure smooth daily clinic operations.

QUALIFICATIONS

Education: A high school diploma or equivalent is required but a strong portfolio and demonstrable experience will be considered in lieu of education.


Experience: A minimum of 1 year of healthcare experience is required, however, pre-med students, CMCP or CMSA, will be considered in lieu of experience.


LICENSURE / CERTIFICATION

• Certified Medical Scribe Professional (CMSP) or Certified Medical Scribe Associate (CMSA) certificate a plus.
• International Medical Graduate, Medical Assistant or LVN/LPN a plus.

KNOWLEDGE, SKILLS AND ABILITIES

• Basic Word, Excel, Power Point.
• Excellent typing and redaction skills.
• Excellent skills to accurately and completely document patients; medical histories, understanding provider's instruction, and for accurately documenting patient's medical information.
• Good judgment, organizational ability, initiative, attention to detail and the ability to be self-motivated.
• Ability to multi-task and work effectively in a high-stress and fast-moving environment.
• Possess a thorough understanding of the importance of confidentiality and non-disclosure according to the general standards set forth by HIPAA.
• Familiarity with and understanding medical terminology.
• Excellent computer and phone skills.
• Impeccable verbal, written and interpersonal skills.
• Bilingual proficiency (especially Spanish) preferred.
• Familiarity with electronic health record systems.

TYPICAL WORKING CONDITIONS

• May be full time remote/telework OR Hybrid
• USA, Texas based

PERFORMANCE REQUIREMENTS

Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI (Protected Health Information) in accordance with organizational policy, Federal, State, and local regulations.