Scribe

JOB DESCRIPTION

POSITION: Ophthalmic Scribe

DEPARTMENT: Clinical

REPORTS TO: Clinical Manager

JOB SUMMARY: This individual is responsible for providing accurate documentation and summary of the ocular examination and recommendations while maintaining patient flow and communication regarding appointment status.

EDUCATION AND EXPERIENCE:

• High school diploma.
• Basic understanding of algebraic principles.
• Minimum of two years’ experience in a medical office, preferably an ophthalmology office.
• Completion of medical terminology and/or ophthalmic terminology courses.
• Scribe certification (preferably certified ophthalmic assistant).
• Excellent spelling ability.

Must be able to travel with doctor & team.

ESSENTIAL SKILLS AND ABILITIES:

• Training and understanding of HIPAA requirements and the importance of maintaining patient confidentiality.
• Strong, professional interpersonal skills.
• Demonstrated respect for staff and patients.
• Excellent verbal and written communication.
• Team-orientation.
• Management of multiple projects simultaneously.
• Strong organization with attention to detail.
• Legible handwriting.
• Computer literacy.
• Minimum keyboarding/typing speed of 45 wpm.

Ability to educate patients regarding instillation of eye drops and other instructions related to physician’s treatment plan.

RESPONSIBILITIES:

• Correctly and accurately summarizes and documents what the physician verbalizes during an examination, including but not limited to: proper charting of the examination, documenting additions to the chief complaint, assessments, recommendations for treatment (including justification of decisions reached when appropriate), testing ordered/performed ensuring all proper supporting elements needed and findings are properly documented.

• Knows required components of every type of examination for appropriate CPT coding to ensure all elements are accurate, completed and documented properly.

• Understands insurance requirements for quality reporting in order to help practice comply with payer requirements.

• Observes the patient and the physician and assists when appropriate during the exam, including but not limited to: holding the patient’s head in the slit lamp, providing additional medications and/or instruments, following directions in a medical emergency.

• Maintains an awareness of the patient’s verbal and non-verbal communication when the physician is providing instructions as it may be necessary for the scribe to repeat information, provide written instructions, and/or hand out patient education materials for the patient to review at home.

• Ensures patients understand all information and/or instructions given.
• Accurately documents chart errors according to practice protocols.
• Helps maintain the patient flow by filling rooms, assisting patients to check out, through the office flow, performing testing or exam elements if necessary, and any other task needed to keep providers clinic flow.

• Remains with the physician as much as possible during the assigned clinic session, and limits time away from the physician and the patient as documentation may be missed.

• When applicable, prepares accurate eyeglass or contact lens prescriptions and/or medication prescriptions for the physician’s signature prior to the completion of the examination.

• Alerts physician to patient-related forms that need completion.
• When appropriate, and as directed by the physician, completes the superbill or enters billing orders, and/or the check-out form, providing direction to the patient prior to following the physician to the next patient.

• Guides patients to check out after completion of exam and ensures proper follow-up appointments are communicated to the front desk to be made before the patient leaves.

• Learns the personality and preferences of each physician, recognizing differences and abiding by them when working with that particular physician.

• Becomes fluent in the exact requirements of each examination.
• Accommodates the needs of the patient for the exam
• Monitors examination room and any physical limitations the patient may have and makes appropriate decisions based on the patients needs.
• Provides needed assistance to ensure the patients exits the room and facility safely , makes sure the equipment is off, the slit lamp is out of the way, equipment is sanitized, etc. upon exiting the room

• Provides patients with all necessary aid to assist them in exiting the facility safely and to expedite patient flow.

• Evaluates the condition of the examination room to ensure adequate supplies are in stock at all times.

• Notifies physician of changes to the daily schedule, especially emergencies.

• Facilitates communication between the physician and other staff members as helpful to minimize clinic flow disruptions.

• Performs other tasks as required.
• Meets all necessary MIPS requirements on each pt examination, ensures all proper documentation is present and correct before exam finalized, coding is correct to ensure proper billing for exams and testing.

• Monitors and maintains physicians MIPS percentages at 80% or above at all times.
• Monitors physicians schedules on a daily basis and makes proper adjustments when necessary.
• Ensures charts are finalized in a timely manner and within the 72 hours guidelines set.

PHYSICAL ABILITIES:

• Must be able to walk and stand for the entire work shift.
• Must be able to move frequently from standing and sitting depending on exam room configuration during clinic sessions.
• Must be able to type or write legibly in a dimly-lit setting.
• Must be able to hear softly spoken words.
• Must be able to add support for elderly patients getting in and out of exam chairs.
• Lifting required up to 30 pounds.

Job Type: Full-time

Pay: From $18.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Medical terminology: 1 year (Preferred)

Work Location: In person

Salary : $18