Medical Scribe

Job Title

Medical Scribe

Job Description

A medical scribe accompanies the doctor during patient visits to document interactions directly into the electronic medical record (EMR), allowing clinicians to focus fully on patient care. The medical scribe is responsible for real-time documentation of patient history, diagnoses, treatment plans, and other medical documentation as dictated by the assigned doctor for which the scribe is assisting. A medical scribe participates in patient care indirectly by working alongside the doctor or surgeon.

Responsibilities

Essential skills include basic knowledge of ophthalmic and optometric exams, procedures, pharmacology, and terminology which can be obtained via on-the-job training. Advanced knowledge of proper coding procedures is expected to develop within the first six (6) months of hire. Medical scribes require basic medical, ophthalmology and optometry knowledge as well as specific knowledge preferences/requirements based on doctor subspecialty and patient types. In addition, a medical scribe is expected to have a typing speed of > 60 words per minute, advanced active listening skills, time management skills, and strong attention to detail. A medical scribe must maintain confidentiality and professionalism at all times.

Essential duties include:

Clinical

• Real-time documentation of patient history, physical exams, diagnoses, treatment plans, lab/imaging results, and prescriptions during consultations.
• Assist with EMR/EHR navigation, entering orders, updating charts, and generating referral letters or prescriptions.
• Reviews patient chart to ensure completeness and accuracy of information; ensure documentation meets compliance standards (HIPAA, audits, etc.).
• Assist with patient education regarding conditions as requested by the treating doctor or surgeon
• Maintains cleanliness and orderliness of exam rooms during the workday.
• Complies with all practice procedures and protocols. Complies with all State and Federal regulations.
• Determine if documentation supports E/M vs/ Eye Code, match applicable ICD-10 codes, and appropriately code in-office procedures based on documentation.

Administrative

• Report inventory and supply needs to leadership timely and as needed for supply ordering
• Participate in daily team huddles and regularly scheduled meetings as planned and required.
• Understand and accept responsibility to report potential or suspected errors to supervisor or Compliance Officer
• Contribute to the team effort by completing additional tasks or projects as needed.
• Maintain positive attitude consisting of cooperation, self-motivation, courtesy, and professionalism

Qualifications

Qualifications/requirements include:

• High School Diploma or equivalent
• Prior experience with medical terminology, documentation, and training in an EMR software preferred
• Strong communication and interpersonal skills
• Ability to work in a fast-paced clinical environment.

Company Benefits

We offer a competitive benefits package to our employees:

• Medical
• Dental
• Vision
• 401k w/ Match
• HSA/FSA
• Telemedicine
• Generous PTO Package

We also offer the following benefits for FREE:

• Employee Discounts and Perks
• Employee Assistance Program
• Group Life/AD&D
• Short Term Disability Insurance
• Long Term Disability Insurance

EyeSouth Partners is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.