Certified Medical Assist Scrb

About the role

The purpose of this position is to handle time-consuming clerical responsibilities for physicians during patient encounters. Scribes accompany a physician and directly observe patient encounters. This position accurately documents the events and decision-making in a manner that results in appropriate medical charting.

Responsibilities

• Receiving and greeting all patients and visitors in a professional manner and providing all reasonable assistance.
• Receiving telephone calls, taking and relaying messages accurately.
• Obtaining information from the patient to accurately complete the patient record for payment information, computer input, etc.
• Compiling a focused health record for the providers by locating and organizing disparate parts of each patient’s medical record including past medical records from the EMR systems as well as written charts and past diagnostic studies as needed.
• Recording real time documentation in the EMR system for the provider such as history, physical, and patient course.
• Preparing patient for examination.
• Aiding physician and/or nurse with minor emergency or surgical procedures.
• Performing routine laboratory and EKG tests as ordered and collecting specimens for the lab.
• Administering and recording medication and injections as ordered.
• Interpreting physician's instructions to patients and providing instruction to patients.
• Cleaning and sterilizing instruments and equipment.
• Scheduling office or hospital procedures.
• Preparing procedure orders and accompanying data to be sent to the hospital for inpatient/outpatient studies.
• Managing and adjusting medication dosage under the direction of a physician and following up on patient compliance.
• Managing patient refills and ensuring that medications are dosed correctly, and patient is taking them according to provider instructions.
• Preloading patient information into the EMR - including diagnostic testing, health maintenance, and past surgical history.
• Accompanying physician into the patient examination room in order to transcribe a history and physical exam, and documenting accurately the physician’s encounter with the patient and others present.
• List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
• Transcribing patient orders including laboratory tests, radiology tests, medications, etc.
• Documenting any procedures performed by the physician.
• Identifying any quality measures that are needed for patient and advising the physician.
• Entering the CPT code and ICD-10 diagnosis code that is verbalized by the provider.
• Serve as the patient advocate by communicating the patient’s needs and requests to the appropriate provider.

Organizational Responsibilities

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Patient care providers are required to maintain current BCLS (CPR), and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Education And Experience

• The knowledge, skills and abilities as indicated below are acquired through the successful completion of a high school diploma or equivalent is required.
• Must be a minimum of 17 years of age.
• Must be Certified or Register Medical Assistant through either (1) successful completion of a Certification Exam or (2) through successful completion of an approved two-year Medical Assistant Program and successful completion of a Certification Exam.
• Previous medical office experience.

Knowledge & Skills

• Demonstrates knowledge of and competency in performing patient care procedures, observations, treatments and techniques utilized by facility.
• Requires ability to perform veni puncture.
• Demonstrates high level of interpersonal and communication skills necessary to consistently receive and greet visitors, clients, and staff members in a professional manner.
• Demonstrates well developed communication skills to communicate effectively and clearly to a variety of internal and external contacts.
• Requires knowledge of billing, office procedures and computer skills.
• Demonstrates analytical skills necessary to solve patient problems and interpret data.
• Promotes collaboration and innovation in the clinical services to ensure an interdisciplinary approach to improving health care delivery and the quality of patient care.
• Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically correct English.
• Ability to spell, proofread and edit written text.
• Recognition of physical exam process and ability to record exam details.
• Organizational skills with focus on tracking patient care and improving patient flow.
• Have a solid understanding of quality measures and payer requirements for wellness.
• Be proficient in ICD-10 requirements for documentation purposes.

Working Conditions

• Works in a physician office environment.
• May require lifting or positioning of patients.
• Flexible hours and work schedule required.

Physical Demands

• Requires the physical ability and stamina (i.e., to walk/stand for prolonged periods of time, push carts/wheelchairs, lift at least 50 pounds, to position).