Certified Medical Assistant/Medical Scribe

About the role

The Certified Assistant/Medical Scribe works under the direct oversight and presence of the Provider (Physician and/or Licensed Independent Provider).

Responsibilities

• Accurately and thoroughly document medical visits and procedures as they are being performed by the provider.
• Record patient chief complaint, reason for visit, medical history, review of systems and physical exam.
• Document procedures and treatments performed by providers.
• Record patient orders, including laboratory tests and imaging tests.
• Provide patient education and explanations of risks and benefits.
• Document provider-dictated diagnoses, codes, prescriptions, and instructions for patient or family members for self-care and follow-up.
• Look up past medical records, track and enter results at the direction of the provider.
• Review the record and ensure documentation requirements for assigned codes have been met.
• Edit provider's medical documents for accuracy, spelling, punctuation, and grammar.
• Identify and correct mistakes or inconsistencies in medical documentation.
• Ensure all clinical data, lab or other test results, and provider interpretations are recorded accurately in the medical record.
• Comply with documentation compliance standards and legal/ethical requirements for preparing medical documents and keeping patient information confidential.
• Prepare referral letters as directed by the provider, via dictation or summary of the medical record.
• Ensure referral letters are mailed or faxed on a daily basis with all copies of pertinent reports or tests attached.
• Research and coordinate referrals, prepare operative reports, make phone calls, and perform other clerical tasks as assigned.
• Collect, organize, and catalog data for provider quality reporting system and other quality improvement efforts, formatting for submission.
• Absorb and assist in developing and maintaining systems to track patient follow-up and compliance.

Departmental and Additional Job Responsibilities

• Assist with patient procedures, taking patient medical histories, instructing patients about medications, tests, and procedures.
• Perform vision and diagnostic tests, coordinate patient scheduling, and supervise and train other allied ophthalmic personnel.
• Communicate effectively with providers and all members of the healthcare team, building and maintaining a mutually respectful working relationship.
• Participate in staff meetings, handle difficult and sensitive situations tactfully, and respond well to supervision.
• Train new employees as needed.

Qualifications

• High school diploma or equivalent required.
• Credential through AAMA (American Association of Medical Assistants) as a CMA, AMT (American Medical Technologists) as an RMA, NHA (National Health Career Association) as a CCMA, or NCCT (National Center for Competency Testing) as a NCMA, or AAH (American Allied Health) as an RMA.
• Current Basic Life Support certification required upon hire.
• Experience working with medical providers and allied health professionals.
• Knowledge of medical terminology preferred.
• Familiarity with requirements for accuracy and speed of typing of multiple medical reports required.