Scribe

Medical Scribe

The role of the Medical Scribe is critical for effective, accurate and excellent patient care. Accuracy and efficiency of the scribe and medical records team directly impacts our mission to be the leader in physician-managed healthcare services and to provide excellent surgical and clinical care for every patient, every day.

Proliance physicians rely on the Medical Scribe to be present with the physician, providing assistance as directed and to extract the relevant information from all patient encounters.

Location: Proliance Puget Sound Orthopaedics (Lakewood, Tacoma & Gig Harbor)

Schedule: 20-30 hours per week

Key Duties and Responsibilities:

• Accurate and thorough documentation of medical visits and procedures as they are being performed by the physician remaining side-by-side with the physician on every patient exam
• Providing assistance in patient care as requested; setting up for procedures as directed; answering all telephone calls into the exam room for the provider and relaying complete caller information to the provider discretely.
• Obtaining the accurate chief complaint(s) and consistently documenting the three constitutional exam elements
• Anticipating and accommodating individual physician preferences or specific protocols.
• Navigating throughout systems software to find necessary information pertaining to the patient.
• Ensuring that patient history form is complete, including "no" answers to "normal"
• Reviewing and modifying the HPI along with additional pertinent information that the patient may offer the physician
• Documenting detailed information and inputting data into patient's medical record as directed by the physician.
• Operating as a go-to/point person for billing questions as indicated by physicians coding choices. Consistently resolving issues with expertise
• Maintain responsibility for finding and entering the correct diagnosis codes in the EMR plan page.
• Documenting findings of diagnostic tests into EMR as directed by the physician.
• Completing the chart (under the direction of the physician), preparing to generate and fax completed note to the referring physician within 24 hours.
• Reviewing log procedures performed in the office by the physicians in order to ensure billing accuracy.
• Spotting mistakes or inconsistencies in medical documentation and checking to correct the information in order to reduce errors
• Facilitating the patient through the clinic into designated areas with proficiency (if the room coordinator is not available).
• Expected to assist with handling phone triage, prescription refills, and lab requisitions.
• Complete duties and assist others as directed
• Follow all policies as introduced during new associate On-Boarding, updated real-time and outlined in Associate Handbook

Education/Experience:

• High School Diploma or the equivalent plus a minimum of one-year experience in a medical office
• Experience and/or certification as a medical assistant is strongly preferred
• Current/recent knowledge ICD-10-CM and CPT coding is necessary

Knowledge, Skills and Abilities:

• Exhibits an excellent knowledge of medical terminology, including familiarity with the spelling, vocabulary and common abbreviations associated with the designated physician center
• Ability to properly code and report medical record data according to CMS guidelines.
• Strong keyboard, computer skills and working knowledge of MS Word
• Superior customer service skills
• Great interpersonal skills; demonstrating patience, composure and cooperation; working well with all patients, physicians and staff.
• Understanding of and adherence to all safety, risk management and precautionary procedures, including the consistent respect for confidentiality (HIPAA)
• Using time efficiently, with meticulous attention to detail, accuracy and completion
• Resourcefulness in addressing and trouble-shooting first level problems and tenacity to see things through to solution; exercise judgment when involving others
• Demonstrated ability to perform in a high-volume, fast paced environment
• Ability to remove oneself personally from given situations, remaining objective
• Able to adapt to change, delays or unexpected events while maintaining a positive mindset
• Clear oral and written communication
• Ability to provide feedback to improve performance
• Self-motivated; able to work independently, measure self against standard of excellence, overcome obstacles and challenges with little to no supervision.

Work Environment/Physical Demands:

The work environment/physical demands described here are representative of those that must be met by a teammate to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable differently abled persons to perform the essential functions.