Clinic Scribe

Position Summary

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.

This scribe position is at the elbow of the provider 2-3 days a week and AI scribe review/clean up 2-3 days a week. This may become AI scribe clean up/review 5 days a week at a computer.

Schedule

Monday-Friday, 8am-5pm.

Key Duties and Responsibilities

The key duties and responsibilities of the Medical Scribe include, but are not limited to:

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 proficiently (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.