Medical Records (CNA)

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Certified Medical Assistant
02 - Medical- HAL FullTime ALTAMONTE OFFICE, Altamonte Springs, FL, US

30+ days ago Requisition ID: 1008

Salary Range: $17.00 To $25.00 Hourly

Maintains effective communication with patients in reference to waiting time, patient needs and expectations, and patient feedback

Escorts patient to the different areas within the medical office (prevention counselor, check-in/out, lab, exam room, social work, including televisit)

Completes all tasks sent via CCR’s EHR by the requested timeframe

Ensures compliance with health center’s policies and procedures as it relates to medical examination of every patient seen

Administrative Duties

Ensures proper and timely check-in of patients and prepares patient for medical examination Assists with the coordination of patient flow

Ensures proper patient identification using a minimum of two (2) patient identifiers as per national patient safety goals requirement

Schedules follow-up appointment for the patient

Timely and accurate documentation in patient charts

Receives/sends documents via fax per provider request:

Medical Record Release Form

Makes phone calls and documents in EHR per provider request

Records pertinent information on forms

Ensures proper and smooth operational flow as it relates to patient visit (i.e. prioritizes patient flow based on medical needs)

Ensures proper patient identification using a minimum of two (2) patient identifiers as per national patient safety goals requirement

Reviews and documents the patient's vital signs in CCR’s EHR

Updates and records patient information in CCR’s EHR:

Allergies, reconciles medication list, reviews immunizations, history forms other information as required

Prepares and reviews the next day’s patient schedule & care requirements to maintain patient flow

Assists with the completion of forms as needed:

PrEP Screening, HIV Confidential Case Forms, Pre-operative Surgical, Work Excusal/Return to Work, and Proof of Pregnancy

Ensures proper Patient Health Questionnaire-9 (PHQ-9) Depression screening for risk of suicide of every new patient

Clinical Duties

Collects and accurately documents patients’ vital signs in CCR’s EHR (i.e. height, weight, temperature, heart rate, blood pressure, pulse oximeter and pain level)

Reports abnormal findings to the Registered Nurse and/or Medical Provider Prepares venipuncture forms

Prepares Advance Beneficiary Notice (ABN) forms as required and informs the patient of any costs associated with lab draw

Prepares and completes lab orders/requisition

Ensures proper collection, labeling, and processing of all specimens using a minimum of two (2) patient identifiers prior to drawing blood

Assists Medical Providers with medical procedures/testing by performing:

Electrocardiogram (EKG’s), rapid testing (CLIA waived testing)diabetic, results documentation & log Maintenance (blood glucose, A1C, strep, urine dipstick, urinalysis, pregnancy, Immunochemical Fecal Occult Blood Test (iFOBT), influenza A&B,HIV,HCV)

Reviews visit summary with the patient upon discharge by the provider

Ensures proper processing and specimens are securely enclosed for transport to the lab Clinical Duties

Prepares rooms for clinical examination and patient procedures as directed Ensures materials/supplies/equipment are fully stocked and available

Assists Medical Providers with procedures/testing and ensures proper documentation in the medical record:

Pap smear, colposcopy, biopsy, vaginal cultures, pelvic/breast exam, male exam, incision and drainage, throat cultures, nebulizer treatments and other procedures as indicated by the provider

Obtains and reviews medical records of all diagnostic/lab reports

Collects, transports, disinfects and prepares instruments for sterilization process in accordance with policy and procedure.

Performs high-level disinfection (HLD) and sterilization of instruments, as assigned and as per manufacturer's guidelines

Ensures the following are entered in patients’ EHR:

Chief complaint, history of present illness, problem list, health reminders, patient history, social history, family history, medical/surgical history, and assesses for recent hospitalizations

Performs PHQ-9 Depression screening

Places orders for the following:

Laboratory testing, standing orders, referrals and updates status of any open referrals, new medication and/or medication refills, vaccines and/or injections

Ensures proper ICD-10 coding/charges per diagnosis as per medical providers instructions Enters Uniform Data System (UDS) & Meaningful Use (MU) measures

Enters self-management goals and plan of care

Provides accurate and timely documentation within the same day of intervention and enters other information as requested by the provider.

Quality Assurance/Compliance

Ensures examination rooms are in compliance with the Occupational Safety and Health Administration (OSHA) and Joint Commission (JC) standards

Ensures proper documentation/logging and disposal of medication into the hazardous/black box Receives training and undergoes competency assessments based on evidence-based guidelines and manufacturer's instructions for use

Ensures cleanliness of clinic area and examination rooms

Reports any cleaning or safety observations to the Registered Nurse and/or Office Manager Maintains agency guidelines relating to safety, outreach, and confidentiality Ensures proper handwashing according to Centers for Disease Control and Prevention guidelines Maintains and follows infection control standards and Universal Precautions as per policy and procedure

Provides feedback observations on risk management/safety assessments in the work area to Registered Nurse and/or Office Manager

Understands and appropriately acts upon the assigned role in Emergency Code System Understands and performs assigned role in Agency Continuity of Operations Plan (COOP)

Culture of Service: 3 C’s

Compassion

Greets internal or external customer (i.e. patient, client, staff, vendor) with courtesy, making eye contact, responding with a proper tone and nonverbal language
Listens to the internal or external customer (i.e. patient, client, staff, vendor) attentively, reassuring and understanding of the request and providing appropriate options or resolutions

Competency

Provides services required by following established protocols and when needed, procure additional help to answer questions to ensure appropriate services are delivered

Commitment

Takes initiative and anticipates internal or external customer needs by engaging them in the process and following up as needed
Prioritize internal or external customer (i.e. patient, client, staff, vendor) requests to ensure the prompt and effective response is provided

Other

Participates in training sessions and other meetings as required by the agency and/or funding sources.
Participates in agency developmental activities as requested.
Other duties as assigned.

Travel Required

No.

Qualifications

Skills

Customer Focus

Advanced

Customer Service

Advanced

Compassion

Advanced

Commitment

Advanced

Multitasking

Advanced

Advanced

Microsoft Office

Intermediate

Advanced

Communication

Advanced

Problem solving

Advanced

Preferred

Intermediate

Intermediate

Behaviors

Required

Loyal: Shows firm and constant support to a cause

Team Player: Works well as a member of a group

Enthusiastic: Shows intense and eager enjoyment and interest

Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Dedicated: Devoted to a task or purpose with loyalty or integrity

Motivations

Required

Goal Completion: Inspired to perform well by the completion of tasks

Self-Starter: Inspired to perform without outside help

Flexibility: Inspired to perform well when granted the ability to set your own schedule and goals Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

Education

Required

High School or better.

Experience

Required

2 years: 2 years of related work experience are required.

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