Medical Scribe - Start Your Career in Healthcare!

Baltimore, MD
Apr 20, 2017
Apr 21, 2017
Accountant, IT
Full Time
POSITION SUMMARY: Job Title: Medical Scribe FLSA Status: Non-Exempt Type: Part-time/Full-time Department: Operations Reports To: Chief Scribe A Scribe is trained to relieve the provider of clerical duties; thus allowing the provider to focus more directly on clinical care. A Scribe's role is limited to documentation and efficiency management for the provider. The Scribe is an unlicensed person and exclusively non-clinical. The Scribe does not touch patients and does not engage in any type of patient care. The Scribe observes the provider during patient encounters and performs documentation on the provider's behalf. Under the direction of the provider, the Scribe enters information into the patient's electronic or written chart. All documentation is reviewed and/or edited by the provider. It is signed with an attestation by the provider that the scribed chart accurately reflects all work performed by the provider. ESSENTIAL FUNCTIONS: Duties and ResponsibilitiesChart in real-time as the provider assesses and examines the patientDocument the history, physical exam, assessment and plan, results, procedures, treatment, and physician consultationsRecord provider-dictated diagnoses, prescriptions and instructions for patient follow-upLocate and obtain past medical histories, previous charts, past results and studiesTranscribe ancillary test results and their interpretationsCheck on the progress of labs, imaging studies, and other patient dataRetrieve and display current and past EKGs and imaging films (eg X-rays) for the provider to review and record provider's interpretationUnderstand basic ICD-10 documentation requirementsComply with all national and local PHI laws including in HIPAA and HITECHComply with all facility, department, company policies and proceduresPerform a variety of other non-clinical tasks specific to the local facility Required Education and Pre-requisites This position requires:High school diploma or the equivalentExemplary work ethic and professionalismExcellent verbal and written communications skillsAbility to adapt to individual site needsStrong computer skills - technological savvyA typing speed of 50+ WPM Training Upon hiring, the scribe is expected to successfully complete the following requirements:Classroom trainingMedicolegal documentationMedical facility flowEfficiency managementMedical terminologyPathophysiologyPhysical exam findingsPHI/HIPAA/HITECHEvaluation and Management (E&M) billing basicsICD-10 documentation requirementsFinal examClinical trainingInitial competency assessmentFacility-specific training Physical DemandsThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.Must be able to stand for long periods of timeFrequently required to stand, walk, sit, use hands, handle documents, bend and stoop as needed, and reach with hands and armsRequired to use a keyboard and computer regularly Position Type/Expected Hours of WorkThis is a full-time or part-time position and hours of work and days vary Monday through Sunday depending on the facility contract and scribe hours needed. TravelTravel is expected occasionally for this position between local hospitals and medical facilities, as required by the particular scribe program. Other DutiesPlease note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. Company Description: ScribeAmerica essentially created the medical Scribe industry, we are the nation's most frequently used and largest professional scribe training and management company, present in over 1,700 healthcare facilities, in 50 states and employing more than 13,000 scribes. We have successfully completed medical scribe programs across a wide spectrum of local environments; rural hospitals, urban hospitals, teaching facilities, private practices, and highly political organizations. These successes provide us with expertise that is unparalleled in the industry. Our medical scribes have been able to prove time and time again that they can master any electronic medical record system, while dramatically increasing physician productivity. We've even successfully pioneered the concept of using scribes to mitigate the decrease in efficiency during EHR implementation- the nation's first!

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