The medical scribe will be responsible for capturing accurate and detailed documentation of the medical encounter into the Electronic Medical Record (eClinical Works) in a timely manner. They will provide excellent customer service to our patients, adhering to established protocols and work processes and successfully managing volume without ever compromising quality. Performs job duties in compliance with systems and job specific standards.
Responsibilities
Essential Duties and Responsibilities:
- Cleans and sterilizes all equipment and logs according to organizational policy and/or manufacturers guidelines.
- Demonstrates competency in answering phones, assembling charts, computer data entry and retrieval of computer results.
- Utilizes appropriate technique in performing venipuncture to obtain blood specimens in accordance with agency procedure.
- Copies, prepares records, and stores and maintains appropriate records.
- Maintains universal precautions in the provision of patient care.
- Prepares and processes requisitions for routine supplies in accordance with agency procedures.
- Assists the Nurse Leader with monitoring emergency supplies – O2 tanks, Defib pads/battery, and emergency medication boxes – and promptly reports malfunction, missing or damaged equipment to the Nursing Leader.
- Responsible for documenting refrigerator, freezer and room temperatures daily as indicated, and report any excursion immediately to the clinical supervisor or designee.
- Accurately and thoroughly document medical visits and procedures as they are being performed by the physician.
- Document patient medical history and physical exam.
- Document procedures and treatments performed by healthcare professionals, including nurses and physician assistants.
- Record physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up.
- Collect, organize and document data for physician quality reporting system and other quality improvement efforts and format for submission and reporting.
- Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
- Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding.
- Ensure that all clinical data, lab or other test results, and the interpretation of the results by the physician are recorded accurately in the medical record.
- Comply with specific standards that apply to the style of the medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
- Manage a minimum of three to four patients per hour on average.
- Prepare exam room and any needed equipment and assists/chaperones during examination and treatment of patients.
- Keeps clinical area stocked and in good order. Maintains stock of laboratory supplies. Assures that all materials are kept current and disposes of outdated supplies.
- Assist the physician with basic patient care and medical indicated procedures set-ups as indicated.
- Communicate with clinical operations staff regarding patient needs and follow-up.
- Communicate with patients, pharmacies, and physicians over the phone under physician guidance.
Minimum Education Requirement:
- High School Diploma or equivalent
- Preferred Education Requirement: Associate's Degree
- Minimum Related Work Experience: 2-4 years
Preferred Certification Requirements:
- Certification as Medical Scribe Professional (CMSP)
- Medical Coding Training or Certification
- Experience with use of ECW - E-clinical works.
Sun River Health is a network of over 40 Federally Qualified Health Centers (FQHCs) providing primary, dental, pediatric, OB-GYN, and behavioral health care to over 245,000 patients annually. With a dedicated staff of 2,000 doctors, nurses, and health care professionals, we pride ourselves on delivering high-quality, affordable care to those who need it most. Sun River Health started in 1975 when four African American mothers spearheaded efforts to open our first health center in Peekskill, New York to deliver accessible, high-quality, affordable services to patients in need – no matter their race, religion, income, or insurance status. Today, after 45 years of service, Sun River Health is still delivering on that promise to communities across the Hudson Valley, New York City, and Long Island.
Job Type: Full-time
Pay: $20.50-$22/hr