Medical Assistant/Scribe

NATURE OF DUTIES:

The core responsibility of the Medical Assistant/Scribe is to capture accurate and detailed documentation (handwritten, electronic, or otherwise) of the encounter in a timely manner.  Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider. 

QUALIFICATIONS FOR THE POSITION:

1. Current certification from one of the following: CCMA (Certified Clinical Medical Assistant) certified through the National Healthcareer Association (NHA), RMA (Registered Medical Assistant )certified through American Medical Technologists (AMT), CMA (Certified Medical Assistant) certified through the American Association of Medical Assistants (AAMA), NRCMA (Nationally Registered Certified Medical Assistant) certified through the National Association for Health Professionals, NCMA (National Certified Medical Assistant) certified through the National Center for Competency Testing (NCCT).
2. Preceptorship of 400 clinical hours in Cardiology
3. Basic Life Support Certification
4. Effective Communication Skills

SPECIFIC DUTIES:

Specific duties may vary and can include:

1. Assist the physicians in the care and management of the patient.
2. Maintain a clean safe environment for patients including all exam rooms and hallways
3. Assisting the provider in navigating the EHR
4. Responding to various messages as directed by the provider
5. Locating information for review (i.e., previous notes, reports, test results, and laboratory results)
6. Entering information into the EHR as directed by the provider
7. Researching information requested by the provider
8. Accompany providers in Cath Lab as directed and enters information in real time using your individually assigned security rights to access the HER

  Documentation/Records/Billings

1. Transcribe subjective, objective, and assessed clinical findings in the medical progress notes so that all members of the health care team may treat holistically and any other pertinent information dictated by the physician.  Document pertinent information for the physician concerning the projected plan of care for the patient in the medical record using the subjective, objective, assessment plan format (S.O.A.P.).
2. Provide pertinent information to clerical personnel concerning billing for services rendered by the physician.
3. Complete all necessary and required documentation for each patient encounter.
4. Complete medical records generated in a timely and accurate manner.
5. Create accurate and complete electronic documentation as required and enter electronic messages to other departments to assist with patient flow and document patient wait times.

Other

1. Identify patients meeting criteria for enrollment in PPM/CCM/TCM/RPM. Identify patients eligible for yearly labs and diagnostics.
2. Assist with scheduling, documentation, and any clinical needs as necessary for vein procedures.
3. Assist the front office with scheduling and recalls to ensure timely patient return to clinic and an efficient schedule.

STANDARDS OF PERFORMANCE:

1. Keeps work area neat and organized. Reports safety issues to team leader immediately.
2. Works efficiently and manages time wisely. Assist other employees when all duties are complete.
3. Communicates any problems, difficulties or concerns regarding job duties to the Nursing Team Leader.
4. Performs all duties without significant error occurring with any regularity.
5. Meets all deadlines and timeframes for completion of assignments.
6. Represents CIS in a professional manner at all times. Demonstrates acceptable ability to interact with physicians, staff and “external” customers (patients, family members, insurance companies, home health etc.) on a professional level at all times. Exhibits good communication skills with physicians, patients, team leaders, and co-workers at all times.
7. Exhibits whenever possible a harmonious relationship with other CIS employee in order to accomplish the duties and responsibilities of the position. While perfect harmonious relationships with all employees is sometimes not achievable, not more than an occasional complaint should be received by the Nursing Team Leader about the incumbent of this position.
8. The employee shall work and relate cooperatively with all other employees (internal customers) of CIS to assure optimum care for the patients of CIS and to achieve standards of care set forth by the CIS medical staff.
9. Adheres to the CIS Compliance Plan as it pertains to the above specific job duties. Uses best efforts to maintain compliance by following the CIS Corporate Compliance Plan, attending CIS compliance education, following medical documentation guidelines, and communicating concerns regarding compliance issues.
10. Performs accurate and complete documentation in the patient’s medical record, when applicable. This includes documentation in both the paper record and the electronic medical record (EMR).
11. Work with the electronic medical record (EMR) staff to maintain quality and work towards future EMR development.
12. Maintains patient confidentiality according to the HIPAA standards of privacy and security.