Scribe & Ophthalmic Tech

Job Description

Job Description

Description:

Description

JOB TITILE: SCRIBE & OPHTHALMIC TECH

STATUS: AT-WILL/NON-EXEMPT

Essential Functions

• Greets patients in a courteous, professional, and timely manner.
• Obtains and records accurate patient histories in the EHR system.
• Performs pre-test procedures, including:
  • Autorefractor
  • Confrontational fields
  • Stereo vision
  • Color vision
  • Lensometry
  • Visual acuity
  • Pupil assessment
  • Motility
  • Intraocular pressure (IOP)
  • Dilation (as directed)
• Prepares patients for provider examinations and explains procedures to ensure comfort and cooperation.

• Performs imaging and testing including OCT, fundus photography, slit-lamp photography, and visual fields.
• Ensures accuracy, quality, and proper documentation of all test results.
• Operates and maintains diagnostic equipment according to established protocols.

• Documents provider-patient encounters in real time within the EHR system.
• Accurately records histories, exam findings, diagnoses, procedures, treatment plans, and follow-up instructions.
• Inputs orders for medications, imaging, referrals, and laboratory testing as directed by the provider.
• Prepares and reviews patient charts prior to exams to ensure completeness.
• Supports accurate charge capture by posting exams and procedures to the billing ledger.

• Assists providers during exams and minor in-office procedures, including setup, documentation, patient education, and cleanup.
• Administers ophthalmic drops under provider direction and according to protocol.
• Maintains comfort working in close proximity to patients, including physical contact and potential exposure to blood.

• Accompanies providers during exams when scribing to ensure efficient visit flow.
• Anticipates provider needs and supports schedule efficiency.
• Assists with triage and responds to patient inquiries within scope; escalates medical questions to the provider.
• Communicates effectively with technicians, providers, and front office staff to maintain smooth clinic flow.

• Cleans and maintains exam rooms and equipment in accordance with infection control standards.
• Ensures proper functioning of equipment and reports issues promptly.
• Monitors and restocks supplies, reporting shortages as needed.

• Adheres to HIPAA, OSHA, and company policies regarding safety, confidentiality, and patient care.
• Maintains accuracy and integrity in both clinical work and documentation.
• Demonstrates professionalism, accountability, and attention to detail in a fast-paced environment.

• Collaborates with team members to ensure consistent clinical standards and patient experience.
• Demonstrates flexibility in daily assignments, transitioning between scribing and technician duties based on clinic needs .
• Performs additional duties and special projects as assigned.

MINIMUM REQUIRED EDUCATION AND EXPERIENCE

1. High school diploma or equivalent required.
2. Minimum of one (1) year of prior ophthalmic technician or medical scribe experience required.
3. Knowledge of medical terminology and clinical documentation practices preferred.
4. Proficiency with electronic health record (EHR) systems and computer applications.
5. Certified Ophthalmic Assistant (COA), Certified Ophthalmic Technician (COT), or Ophthalmic Scribe Certified (OSC) preferred but not required.
6. Excellent verbal and written communication skills with strong attention to detail.
7. Ability to work effectively in a fast-paced, multi-site environment.

POSITION REQUIREMENTS

1. Must successfully complete a comprehensive background check as a condition of employment, including prior to any transfer or promotion within the organization.
2. Demonstrates professionalism, integrity, and cultural competence in all interactions.
3. Ability to manage multiple priorities, meet deadlines, and work independently or collaboratively as part of a team.
4. Must be willing and able to travel between assigned clinic locations as needed.
5. Maintains confidentiality of all patient, employee, and company information.

PHYSICAL REQUIREMENTS

1. Ability to sit or stand for extended periods throughout the workday.
2. Frequent use of computer, keyboard, and mouse for data entry and documentation.
3. Manual dexterity sufficient to operate clinical equipment and office devices.
4. Visual and auditory ability sufficient to observe, document, and communicate effectively.
5. Occasional lifting of materials up to 10 pounds.