Medical Assistant/Medical Scribe

JOB TITLE: Medical Assistant/Medical Scribe (Bilingual in Spanish necessary)
PAY RANGE: OPM Pay Grade 5 (Hourly)
FLSA STATUS: Non-Exempt
LOCATIONS: Englewood and Edison, NJ
HOURS: 8am-5pm Monday through Friday

SUMMARY:
The Medical Assistant / Medical Scribe provides administrative and non-certified clinical support to physicians and advanced practice providers by facilitating efficient patient flow, documenting medical encounters in real time, and assisting with routine patient care activities. This position serves as the provider's primary documentation support during patient visits while ensuring accurate medical record completion, timely patient coordination, and an exceptional patient experience. The Medical Assistant / Medical Scribe performs duties under the direct supervision of a licensed healthcare provider and does not perform functions requiring professional licensure or certification.

ESSENTIAL DUTIES AND RESPONSIBILITIES
Accompany providers during patient visits and accurately document patient encounters in the electronic medical record (EMR) in real time.
Record patient histories, review of systems, physical examination findings, assessments, treatment plans, procedures, diagnoses, and provider instructions as dictated by the provider.
Prepare clinical documentation for provider review and signature, ensuring completeness, accuracy, and compliance with documentation standards.
Enter laboratory orders, imaging requests, referrals, prescriptions, and follow-up instructions into the EMR for provider review and approval, when appropriate.
Prepare examination rooms before and after patient visits.
Escort patients to examination rooms and prepare them for evaluation.
Obtain and document patient vital signs, height, weight, and other routine clinical information as directed.
Verify patient demographics, medication lists, allergies, pharmacy information, and medical history.
Assist providers during examinations and in-office procedures by preparing equipment, supplies, and treatment rooms.
Coordinate patient flow to maximize provider efficiency while maintaining exceptional customer service.
Schedule follow-up appointments, referrals, diagnostic testing, and procedures.
Process prescription refill requests according to provider instructions and organizational policies.
Answer incoming telephone calls and respond to patient inquiries within the scope of the position.
Scan, upload, and maintain patient records within the electronic medical record system.
Maintain examination rooms, medical equipment, and supply inventory in a clean, organized, and fully stocked condition.
Provide patients with educational materials and post-visit instructions as directed by the provider.
Maintain strict confidentiality of patient information in accordance with HIPAA and
organizational policies.
Follow infection prevention, OSHA, and workplace safety guidelines.
Collaborate with physicians, advanced practice providers, clinical staff, and administrative personnel to ensure efficient clinic operations.
Adapt to fluctuating patient volumes while maintaining professionalism, efficiency, and attention to detail.
Participate in departmental meetings, quality improvement initiatives, and ongoing education as assigned.
Perform other duties as assigned by management.

QUALIFICATIONS:
Required:
High school diploma or equivalent.
One (1) year of experience in a medical office, physician practice, or outpatient healthcare setting preferred.
Medical Assistant certification is not required.
Working knowledge of medical terminology.
Strong computer skills with proficiency in electronic medical record (EMR) systems.
Excellent typing and documentation skills with a high degree of accuracy.
Strong organizational, communication, and interpersonal skills.
Ability to multitask and prioritize responsibilities in a fast-paced clinical environment.
Ability to maintain patient confidentiality and exercise professionalism at all times.

Preferred:
Previous experience as a medical scribe or provider assistant.
CPR certification.
Experience within orthopedic, spine, pain management, vascular, or surgical specialties.
Bilingual (English/Spanish) preferred.

KNOWLEDGE, SKILLS, AND ABILITIES:
Excellent listening, written, and verbal communication skills.
Strong attention to detail and documentation accuracy.
Ability to quickly learn provider preferences and clinical workflows.
Working knowledge of HIPAA, OSHA, and patient confidentiality requirements.
Ability to remain calm and organized during periods of high patient volume.
Strong customer service and patient relations skills.
Ability to work independently while functioning as an effective member of a multidisciplinary healthcare team.
Demonstrates professionalism, integrity, discretion, and sound judgment.

PHYSICAL DEMANDS:
The physical demands described here are representative of those required to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform these essential functions.

This position requires frequent sitting, standing, walking, bending, reaching, keyboarding, and viewing computer screens for extended periods throughout the workday. The employee must be able to communicate effectively with patients, providers, and coworkers and accurately document medical information during patient encounters. Occasional lifting and carrying of supplies weighing up to 25 pounds may be required.

WORK ENVIRONMENT:
Work is performed primarily in a fast-paced outpatient medical office and clinical environment. The employee may be exposed to bloodborne pathogens and other potentially infectious materials and is expected to follow all infection control, OSHA, and safety protocols. Frequent interaction with patients, providers, and interdisciplinary staff is required throughout the workday.

DOL/FLSA CLASSIFICATION & JUSTIFICATION
This position is classified as Non-Exempt under the Fair Labor Standards Act (FLSA). The primary responsibilities consist of medical documentation, patient coordination, administrative support, routine clinical assistance, and provider support performed under the direct supervision of licensed healthcare professionals. The Medical Assistant / Medical Scribe does not exercise independent clinical judgment, supervise employees, establish organizational policy, or perform duties requiring advanced professional knowledge consistent with the Executive, Administrative, or Learned Professional exemptions under the FLSA. Accordingly, the position is eligible for overtime compensation in accordance with applicable federal and state wage and hour laws.

The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities, or physical requirements. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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