Certified Medical Assistant​/Medical Scribe

Overview

Job Summary
The Certified Assistant/Medical Scribe works under the direct oversight and presence of the Provider (Physician and/or Licensed Independent Provider) and provides annotation, under their login profile, into the Electronic Health Record (EHR) of dictated, written, or verbally communicated information for the treatment of patients, following all local, state and federal regulations/guidelines for documentation. The Certified Medical Assistant/Medical Scribe records each patient’s symptoms, history, physical exam and diagnoses.

They work with the provider to provide patient care by performing tasks under the supervision of the physician. They strive for superior performance by providing a product or service that contributes to the patient and family experience and demonstrate understanding of patient- and family-centered care.

• Accurately and thoroughly document medical visits and procedures as they are performed by the provider, including but not limited to: patient chief complaint, reason for visit, medical history, review of systems and physical exam; procedures and treatments performed by providers; patient orders (e.g., laboratory tests, imaging tests); patient education and explanations of risks and benefits; 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 verify documentation requirements for designated codes; proofread and edit all provider medical documents for accuracy, spelling, punctuation and grammar; identify mistakes or inconsistencies and correct information to reduce errors, ensuring addenda are signed off by the provider; ensure all clinical data and lab results are recorded accurately;
  
  alert the provider when the chart is incomplete.
• Comply with documentation compliance standards for medical records and for keeping patient information confidential.
• Prepare referral letters as directed by the provider, via dictation or summary of the medical record; ensure letters are mailed or faxed daily to all providers involved in a patient’s care with copies of pertinent reports or tests attached; research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and perform other clerical tasks as assigned.
• Collect, organize and catalog data for provider quality reporting and other quality improvement efforts; assist in developing and maintaining systems to track patient follow up and compliance.

• Work with the provider to provide patient care under physician supervision.
• Assisting with patient procedures
• Taking patient medical histories
• Instructing patients about medications, tests and procedures
• Performing vision and diagnostic tests
• Coordinating patient scheduling
• Supervising and training other allied ophthalmic personnel
• Maintain professional relationships with providers, staff and patients; communicate positively and cooperatively with management, staff and other healthcare personnel
• Contribute to team efforts; carry out assignments responsibly; participate in staff meetings
• Handle difficult and sensitive situations tactfully; respond well to supervision; communicate appropriate information to co-workers
• Assist with training of new employees as needed
• Other duties as assigned

• High school diploma or equivalent required.
• Certificate of completion of Medical Assistant program. Credentialed through AAMA (CMA), AMT (RMA), NHA (CCMA), NCCT (NCMA), or AAH (RMA). Recent graduates may be considered prior to credentialing but must obtain within 90 days of hire.
• 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 medical reports.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

• Language
  
  Skills:
  
  Proficient in typing; clear spelling, punctuation, grammar; ability to listen to complex medical information and summarize clearly; excellent English composition; legible handwriting.
• Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to understand and accurately transcribe dictated reports. Translate medical abbreviations.
• Mathematical
  
  Skills:
  
  Basic arithmetic, chart interpretation, and ability to compute ratios and percentages.
• Reasoning Ability:
  Ability to follow instructions, apply logic, refer to reference materials and solve problems.
• Computer
  
  Skills:
  
  Ability to learn and use EMR and transcription software; enter data accurately;…