MEDICAL SCRIBE- EVERGREEN

Franklin Primary Health Center, Inc.; Alabama; Hybrid; USD 40,000 - 52,000; Full time

Job summary

Franklin Primary Health Center, Inc. is seeking a Medical Scribe to assist assigned physicians in a clinic setting. The role focuses on clerical and IT support to increase physician efficiency and productivity, with attention to detail and self-motivation.

The Scribe documents visits, prepares referrals, and manages communications while maintaining patient confidentiality and HIPAA compliance in daily clinic operations.

Qualifications

• Must have a high school diploma or GED and medical terminology knowledge.
• Graduate of an approved Medical Scribe program or equivalent training.
• Ability to translate medical abbreviations and summarize dictated reports.

Responsibilities

• Accurately document visits and procedures in real time for physician use.
• Prepare referral letters and manage dictated reports and communications.
• Maintain patient confidentiality and HIPAA compliance at all times.
• Assist in data collection for quality reporting and improve workflow efficiency.
• Support clerical tasks and ensure chart completeness with physician oversight.
• Participate in training and adapt to practice workflows within the clinic.

Skills

Medical terminology

Anatomy & physiology

Typing

English composition

Oral communication

Education

High school diploma or GED

Medical Scribe program graduate

Tools

Microsoft Word

Microsoft Excel

Job description

Department: Medical
Classification: Non-Exempt
Reports to: Director of Nursing

Job Summary

The Medical Scribe assists their assigned physician by performing all clerical and information technology functions for the physician in a clinic setting. The primary goal of the Medical Scribe is to increase the efficiency and productivity of the practitioner (physician and/or mid-level provider). Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important when working as a Medical Scribe. The Scribe must be adaptable and versatile and maintain good attendance. The Scribe must be able to anticipate the practitioner (physician and/or mid-level provider) needs to facilitate the flow of clinic.

Essential Functions

• Participates in Care team huddles and initiates pre-visit planning workflow to ensure Physician Care Plan completion prior to visit whenever possible.
• Maintains confidentiality at all times.
• Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician, including but not limited to:
  • Patient medical history and physical exam;
  • Procedures and treatments performed by healthcare professionals, including nurses and physician assistants;
  • Patient education and explanations of risks and benefits;
  • Physician-dictated diagnoses, prescriptions, and instructions for patient or family members for self-care and follow-up; and
  • Preparation of referral letters as directed by the physician.
• Performs dictation, faxing, phone calls, and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribes also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, with all copies of pertinent reports or tests attached. May be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and perform other clerical tasks as assigned.
• Monitors for mistakes or inconsistencies in medical documentation and checks to correct the information in order to reduce errors. All addenda must be signed off by a physician.
• Ensures 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. Alerts the physician when the chart is incomplete. Medical Scribes must comply with specific standards that apply to the style of medical records and the legal and ethical requirements for preparing medical documents and keeping patient information confidential.
• Monitors physicians’ open encounters and PAQ and assists providers in addressing them to maintain compliance.
• Collects, organizes, and catalogs data for physician quality reporting and other quality improvement efforts and records information in the EHR and formats it for submission.
• Assists in developing and maintaining systems to track patient follow-up and compliance.
• Attends training on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing, and coding. Quickly assimilates new knowledge into processes and procedures. Medical Scribes proofread and edit all physician medical documents for accuracy, spelling, punctuation, and grammar.
• Participates in Care team quality improvement activities, including Care team performance on required clinical, operational, and financial measures.
• Performs any other duties deemed necessary by the immediate supervising physician/Nurse Manager.

The above reflects the general duties considered necessary to describe the principal functions of the job and shall not be considered a detailed description of all work that may be assigned by the immediate supervisor and/or health care provider or that may be inherent in the position as it relates to each specialty group (i.e., Family Medicine, Internal Medicine, Pediatrics, OB/GYN, etc.).

Customer Satisfaction Requirements

Must provide the very best customer satisfaction to patients, visitors, and co-workers at all times in a professional and courteous manner. Provide assistance in resolving customers’ problems. Coordinate efforts and interfaces with other departments to resolve problems. Actively protects customer confidentiality. Actively keeps the environment clean and safe with a professional and welcoming image. Always treats customers as welcome guests and provides a warm and sincere greeting. Consistently presents a professional appearance in dress and grooming by adherence to dress code policy. Effectively and regularly demonstrates the values of the organization. Effectively involves customers in decisions that affect them. Follows through in a timely manner on commitments made to customers. Takes ownership of attitude toward Service Excellence.

Performance Standards

Performance will be evaluated by the Supervising Physician or designee annually wherein an overall satisfactory rating is considered a minimum acceptable level of performance.

Privacy Rule Compliance Requirements

• Adheres to Health Insurance Portability and Accountability Act (HIPAA Privacy Rule) policies and procedures.
• Must successfully complete Privacy Rule compliance training annually or as revisions are made to the policies and procedures.
• Must comply with Privacy Rule guidelines by learning to protect FPHC patients’ medical privacy.
• Must comply with Privacy Rule guidelines by appropriately maintaining patient information in compliance with national standards.
• Must comply with Privacy Rule guidelines by providing appropriate security of FPHC patient records.

Health and Safety Requirements

The health and safety requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• Must adhere to safety regulations, personnel policies, and procedures.
• Safety and Hazard Communication training update is required annually.
• Knowledgeable of OSHA and CLIA requirements to assure compliance.
• Maintain yearly health maintenance records by obtaining TB skin testing and completion of the hepatitis series.

Protected Health Information (PHI) Access

RESTRICTED – For purposes of HIPAA Compliance, there are four workforce categories that define the level of access to PHI granted to the incumbent. This position is classified under PRIMARY PROVIDERS and therefore granted RESTRICTED access, to be defined according to the workforce member’s specific job duties. Use and disclosure must be in accordance with applicable privacy policies and procedures.

Qualifications

Education and Experience

High school graduate or GED equivalent. Graduate of an approved Medical Scribe Program or an equivalent combination of training, education, and work experience relative to the position. One or more years of work experience in a medical setting with knowledge of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports. Must be able to translate medical abbreviations into their expanded forms. CPT coding and Medicaid, Medicare, and other third-party insurance carrier billing experience preferred. Must have the ability to write routine reports and correspondence.

Knowledge, Skills and Abilities

Requires knowledge of the field of assignment sufficient to perform thoroughly and accurately the full scope of responsibility as illustrated by examples in the job description. Requires human relations skills to deal effectively with patients and visitors in person or via telephone. Must have keyboard experience and knowledge of medical records and insurance billing. Possess basic ability to operate a multi-line telephone, copier, adding machine, fax machine, and other office equipment.

CPT coding and Medicaid, Medicare, and other third-party insurance carrier billing experience preferred. Possess the ability to write routine reports and correspondence. Must demonstrate proficiency in typing, spelling, punctuation, grammar, and oral communication. Must be able to listen to complex medical information and summarize it in a clear, complete, and concise fashion. Excellent English composition skills are required to generate professional, polished writing at a high rate of production.

Must have the ability to add, subtract, multiply, and divide in all units of measure using whole numbers, common fractions, and decimals; prepare and interpret charts and graphs; and compute ratios and percentages. Must accurately enter data into a database, search for information, and send and receive email and attachments. Proficiency in Microsoft Word and Excel is required, as well as the ability to use the internet to access schedules, research information, and perform related functions.

Certification, Licenses and Registrations

CPR

Physical/Mental Demands

Requires eye-hand coordination and manual dexterity. Requires the ability to distinguish letters or symbols. Requires the use of office equipment such as copiers, computer terminals and keyboards, telephones, calculators, and fax machines. Requires normal vision range. Requires frequent standing, sitting, bending, stooping, or stretching. Must be able to lift and move patients as needed.