Medical Scribe

Summary: The Finalizer will assist physicians with various administrative aspects of patient care in the clinic, under the direction of the physicians. These administrative aspects include assisting with recording the medical record documentation (electronic or paper) of patient history, review of systems, physical exam findings, progress notes, procedure notes, follow-up of laboratory and diagnostic results, arranging and expediting consults, and assisting with recording the documentation for patient admission, transfer or discharge plan and follow-up.

Essential Functions:

· Maintain safe, secure, and healthy work environment by establishing and following standards and procedures and complying with legal regulations.

· Secure patient information and maintain patient confidence by completing and safeguarding medical records; completing diagnostic coding and procedure coding; keeping patient information confidential.

· Complete records by recording patient examination, treatment, and test results.

· Prepares and assembles medical record documentation/charts for physician(s).

· Enters the patient room with the physician during patient visit to capture and transcribe medical record documentation utilizing electronic medical record applications.

· Update’s patient history, physical exam, and other pertinent health information in the patient

· Prepares and sends all documentation to physician for review and approval via authentication of detailed data entry.

· Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.

· Monitor charts to ensure timely completion including history, physical exam, review of systems, labs, diagnostic studies, ECGs, initial assessment and plan, progress notes, procedure notes, impression/diagnosis, discharge plan with disposition, and signatures. Send incomplete charts back to the appropriate physician(s) as needed.

· Communicate with patients and informing them about normal or abnormal laboratory test results as instructed by Clinic Manager.

· Assist with the training of new Finalizer / hires as needed.

Education and Experience:

· Completion of accredited Medical Assistant Training Program.

· Physical examination which indicates that the employee can meet the physical requirements of the job including Lifting, Walking, Stooping, Bending, And Twisting.

· Skilled in Microsoft Office, data entry, and use of business email.

· Bilingual in English and Spanish is preferred but not required.

· Serve and protect the physician or healthcare provider practice by adhering to professional standards, policies, and procedures, HIPPA regulations, federal, state and local requirements and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards

· Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Translate medical abbreviations into their expanded forms.

Certification and Licensure:

· Medical assisting certificate.

· Associates preferred.

Work Environment:

· Fast-paced environment with occasional high-pressure situations

· Environmentally controlled medical office environment

· Frequent interaction with a diverse population including team members, providers, government officials, patients, insurance companies and other members of the public.

Physical Demands:

· Frequent sitting, writing, typing, grasping and speaking.

· Occasional standing, walking, reaching, bending, stooping, lifting and carrying.

· Lifting, carrying, pushing and pulling up to 25 pounds.

· Frequent use of computer, keyboard, copy and fax machine and phone.

SCMC has reviewed this job description to ensure that essential functions and basic duties have been included. It is intended to provide guidelines for job expectations and the team member's ability to perform the position described. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors, managers, executives, or officers as deemed appropriate. This document does not represent a contract of employment, and SCMC reserves the right to change this job description and/or assign tasks for the team member to perform, as SCMC may deem appropriate.

Job Type: Full-time

Pay: Up to $21.00 per hour

Benefits:

• Dental insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Medical Specialty:

• Primary Care

Experience:

• Medical Scribe: 1 year (Preferred)

Work Location: In person

Salary : $21