Medical Scribe

• In accordance with policy, prepares and assembles medical record documentation/chart for physician prior to patient visit
• Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results
• Ensures that all elements of documentation are complete and accurate
• Enters the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications
• Documents the physician/clinician's communication with the patient using appropriate medical terms and phrasing
• Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders
• Documents the correct follow-up instructions and level of service designation based on the physician/clinician's direction
• Assists in data entry from devices or other sources
• Completes medical records for each encounter ensuring accurate and timely documentation
• Under physician/clinician direction, updates patient history and other pertinent health information in the patient record
• Prepares and sends all documentation for review and approval
• With proven competency, may perform clinical functions such as prepare and room patient for exam, obtain vital signs and document/update pertinent health information, assist the physician/clinician with non-sterile procedures, schedule appointments and referrals to other facilities or services, and perform other data entry into the EHR

• High School Graduate
• Typically requires 1 year of experience in medical assisting, medical transcription, emergency medical services, patient service and/or as a health care professional with demonstrated proficiency in medical terminology and technical spelling
• Knowledge of medical terminology, including basic human anatomy and coding
• Knowledge of essential elements of documenting a provider-patient encounter, HIPAA compliance, and Centers for Medicare and Medicaid Services requirements
• Excellent communication and interpersonal skills
• Proficient computer skills including: advanced keyboarding, above average typing speed, navigation within a windows operating system, and use of electronic mail with exposure to electronic medical records systems
• Ability to effectively multi-task, with excellent prioritization and organization skills
• Must have a high attention to detail and accuracy when documenting health information
• Ability to work effectively in a fast paced and stressful environment
• Must have ability to travel to various work locations

May need successful completion of authorized medical scribe training course within 30 days of hire

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program