Medical Scribe/Medical Assistant

SUBJECT: JOB DESCRIPTION- CLINICAL SCRIBE

STATUS: Non Exempt

Reports To: Clinical Manager/Director

SUMMARY:

Clinical Scribe duties include performing all clerical and information technology functions for a provider in a clinic setting. This includes primary responsibility of the operation of electronic health record system. A Clinical Scribe is able to anticipate physician needs to facilitate the flow of the clinic.

ESSENTIAL DUTIES AND RESPONSIBLITIES:

1. Ensure accurate and detailed documentation as per the provider(S) instruction.

2. Accurately and thoroughly document clinical visits and procedures performed by the Provider, including but not limited to:

a. Patient Clinical history and physical exam.

b. Procedures and treatments performed by provider

c. Patient education and explanation of risks and benefits.

d. Provider-dictated diagnosis and instructions for patient or family members for self-care and follow-up.

3. Assist Provider in navigating the electronic health record(EHR)

4. Locates information for review and implements key components into documentation

5. Champions quality initiatives and implements key components into documentation.

6. Troubleshooting basic IT needs (i.g. printer setup, etc.)

7. Notifies provider of any pending items/system alerts.

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8. Actively participates in huddles with care team.

9. Understanding clinical Scribe scope of practice and maintain awareness of any changes

10. Attend training on diverse subjects as needed to enhance or maintain performance.

11. Perform other duties as requested.

QUALIFICATION: To perform this Job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and /or ability required.

1. Language Skills: - The ability to write routine reports and correspondence. Clinical scribe must be proficient in typing and good at spelling, punctuation, grammar, and oral communication. Must be listening to complex Clinical information and summarize in clear, complete and concise fashion. Excellent English composition skills required to generate professional, polished writing at high rate of Production. Handwriting must be clear and legible.

2. Understanding of Clinical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent require to understand and accurate transcribe dictate report forms.

3. Mathematical Skills – Ability to add, subtract, multiply, and divide in all units of measure, using whole number, common fractions, and decimals. Prepare and interpret charts and graphs. Have the ability to compute ratio and percent.

4. Reasoning Ability – Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Have the ability to refer to reference materials to solve problems.

5. Computer Skills – To perform this job successfully, an individual should be able to learn and use all functions of electronic health record software. Must accurately enter data into a database, search for information, send and receive email and attachments. Must be proficient in Microsoft Word in order to prepare correspondence, Clinical reports, and other documents.

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6. Other Skills and Abilities – Must be able to type words and numbers quickly and accurately.

7. Must comply with HIPPA confidentiality standards when accessing or communicating patient information.

Minimum Qualifications:

1. High school diploma or equivalent

2. Medical Assistant/ Licensed Vocational Nurse or other healthcare education/ certificates/or work experience

3. Preferred recent applicable experience (2-5 years)

Special Conditions of Employment:

1. Valid Driver’s license.

2. Current and Valid CPR and First Aide certification on file with the Human Resources Department. This is for clinical and administrative staff. This new license requirement is mandatory for continued employment, CPR and First Aide certification must be obtained through the American Heart Association. Internet certificates do not comply and for this reason are not valid.

3. Successful passing of the Screening Assessment Tools.

Knowledge, Skills and Abilities:

1. Excellent oral and written communication skills.

2. Effective interpersonal skills.

3. Bilingual in languages as applicable to populations served.(Spanish)

4. Clinical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract Clinical staff from patient care.

5. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Clinical Scribe.

6. Clinical Scribe are adaptable and versatile since as they are responsible for many tasks.

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Physical and Mental Requirements:

1. Able to lift/move up to 40 pounds, move from place to place, and stand for long periods of time

2. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress

3. Ability to supervise, multitask, understand and follow instructions

4. Ability to proficiently read, writes, speaks and understands English & Spanish.

CUSTOMER SERVICE:

1. Actively supports, promotes, and works to fulfill the Mission, Vision and core values of Keen Medical Group.

2. Provides excellent internal and external customer service.

3. Demonstrates Keen Medical Group Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.

4. Participates in on-going customer service trainings.

5. In every action, seeks to promote KMG as a top service organization.

QUALITY MANAGEMENT:

1. Contribute to the success of the organization by participating in quality improvement activities.

2. Complies with all Keen Medical Group’s policies and procedures and pro-actively participates in the implementation of new initiatives.

SAFETY:

1. Ensures compliance with policies and procedures related to safe work practices.

2. Uses all appropriate equipment and/or tools to ensure workplace safety.

3. Immediately reports unsafe working conditions.

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PRIVACY/COMPLIANCE:

1. Maintains privacy and security of all patient, employee, and volunteer information and access to such information. Such information is accessed on a need to know basis for business purposes only.

2. Complies with all regulations regarding corporate integrity and security obligations. Reports unethical, fraudulent or unlawful behavior or activity.

3. Upholds strict ethical standards

Flexibility: Available for all shifts and, when required, able to work evenings and weekends.

Print Name: _____________________________ Date: ___________________

Signature: _______________________________ Date: __________________

Benefit Conditions:

• Waiting period may apply
• Only full-time employees eligible

COVID-19 Precaution(s):

• Personal protective equipment provided or required
• Plastic shield at work stations
• Temperature screenings
• Social distancing guidelines in place
• Sanitizing, disinfecting, or cleaning procedures in place

Work Remotely

• No

Job Type: Full-time

Pay: $16.50 - $19.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Health insurance

Medical Specialty:

• Primary Care

Schedule:

• 8 hour shift

Education:

• High school or equivalent (Required)

Experience:

• Typing: 2 years (Required)
• Medical Terminology: 2 years (Required)

License/Certification:

• M.A. & scribe License (Required)

Work Location: In person

Salary : $17 - $19