Ophthalmic Clinic Scribe

Responsibilities

• Correctly 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, assessment and recommendations for treatment including justification of decisions reached when appropriate and closing patient charts in a timely manner.
• Accurate ICD10 and CPT coding in patient charts
• Observes the patient and the physician and assists when appropriate during the exam including but not limited to; providing assistance to the patient as needed, 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.
• Accurately documents amendments to patient charts according to practice protocols.
• Maintains the patient flow of the clinic to include confirmation of insurance authorization prior to treatment
• Provides support to the clinic by helping execute Ophthalmic Technician duties as needed
• Alerts physician to patient-related forms that need completion.
• Guides patients to front desk after completion of exam and ensures proper follow-up appointments are communicated to the front desk to be made before the patient leaves.
• Evaluates the condition of the examination room to ensure adequate supplies are in stock and patient can safely enter and exit the room
• 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 assigned.

Qualifications

• Knows required components of examination for appropriate CPT coding to ensure all elements are accurately completed.
• Understands Medicare and other common insurance requirements for quality reporting in order to help practice comply with payer requirements.
• Training and understanding of HIPAA requirements and the importance of maintaining patient confidentiality.
• Strong, professional interpersonal skills.
• Excellent verbal and written communication.
• Team-orientation.
• Ability to multi-task.
• Strong organization with attention to detail.
• Computer literacy.
• Ability to spell accurately while charting
• Basic math skills
• Fluency in English, bilingual preferred.
• Ability to educate patients regarding instillation of eye drops and other instructions related to physician’s treatment plan.
• Understanding of medical terminology and/or ophthalmic terminology.