Medical Scribe

Job Summary:

The intent of this job description is to provide a summary of the major duties and responsibilities performed in this job. Incumbents may be requested to perform job-related tasks other than those specifically presented in this description.

The goal of this position is to be the personal data assistant to the Provider, and to assist with assuring that our patients are receiving high quality, comprehensive healthcare. This means you are responsible for transcribing patient visits with accurate and detailed information, communicating and collaborating with multiple members of the care team, and building your understanding of the healthcare delivery system.  This role also interfaces with the quality/care management team to improve best practices. Medical Scribes are trained to be experts in structured clinical assessments, accurate and specific documentation and team based, patient-centered care.

We start simple: build meaningful relationships with patients and their families, then layer resources to help our teams provide excellent care. We emphasize the use of technology to improve care quality and make life easy for our providers. Please note that this is a full-time position, 40 hours per week.

Essential Job Duties: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Maintains records and assists with clinical paperwork (i.e., refills, orders, forms, referrals, etc).
• Helps clean and maintain workstation and exam rooms.
• Places orders and completes inbox items at the direction of the healthcare provider.
• Work cooperatively with others, including appropriate communication with patients, providers, support staff, and administration.
• Review and prepare patient charts prior to visit with Provider including review and preparation of the patient’s chronic medical conditions and care quality measures.
• Research existing chart documentation, legacy EHR, and outside medical records to discover and validate Risk Adjusted Diagnosis (HCC Codes) and build documentation in the patient's problem list and current encounter.
• Observe and record Patient encounters/examinations by accompanying the Provider into the exam room or via virtual connection.
• Transcribe Patient visits with accuracy and detailed information.
• Transcribe the Patient history, physical exam findings, consultations, labs, x-rays, and other evaluations, as stated by the Provider.
• Document any procedures, medications, injections, and tests that are either ordered or completed by the Provider.
• Prepare care plans and patient facing instructions as directed by the Provider, communicate/collaborate with the care-team to assure that all elements of the care plan are addressed and completed.
• Communicate with the care team including Medical Assistants, Referrals Coordinator, Case Management, and scheduling team on any follow up, procedures or orders that may be needed.
• Maintain up-to-date information for the Provider(s) during every visit, if necessary.
• Prepare for and provide patient education documents, as needed. These may be from the EHR library or could be company specific.
• Other duties as assigned.

Required education and experience: The requirements listed below are representative of the knowledge, skills, and/or ability required.

Minimum Education (or substitute experience) required:

• High school diploma or equivalent (GED).
• Bachelor’s degree.

Minimum Experience Required:

• Successful completion of a scribe training or medical assisting program preferred.

Minimum Knowledge and Skills Required:

• Bilingual Spanish is preferred.
• Knowledge of medical terminology.
• Ability to type 65 words per minute. 
• Ability to communicate effectively and congenially with patients and staff members in person and over the phone.
• Ability to exercise tact, initiative, and good judgement when interacting with patients and staff.
• Ability to record observations and notes completely, accurately, literately, and concisely.
• Ability to learn and code for Hierarchical Condition Categories.
• Computer skills necessary to navigate the company’s EMR system.
• Ability to accept supervision and feedback.
• Understand HCCs and Medicare.

Desired Traits

• Possess a selfless, team-player mentality.
• Known for their dependability and reliability.
• Strives for excellence.
• Capacity to prioritize tasks.
• Pursuing a career in medicine (i.e. – Doctor, Physician’s Assistant, Nurse Practitioner, etc.)

Travel required: 10% in the surrounding Temecula, CA area from Hemet, CA to Fallbrook, CA.

Training will take place over a 2 week span with travel required to multiple office sites within the surrounding Temecula, CA area from Hemet, CA to Fallbrook, CA.