Medical Scribe

Job Title: Medical Scribe Department: Clinic Reports to: Clinic Manager 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 Prepares documents and correspondence using dictation or written medical records Reviews medical documents and report and correct errors or inconsistencies 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. Collects, organizes, and stores data in written or electronic form Helps maintain the patient flow by seating patients into empty exam room to prep for physician. 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.

Becomes fluent in the exact requirements of each examination. Accommodates the needs of the patient for the exam Ensures patient understands all instructions. Evaluates the condition of the examination room to ensure adequate supplies are in stock. Complies with HIPAA (Health Insurance Portability and Accountability Act), ethical and legal regulations Skills/Abilities Familiarity with medical terminology Training and understanding of HIPAA requirements and the importance of maintaining patient confidentiality.

Strong, professional interpersonal skills. Demonstrated respect for staff and patients. Excellent written and verbal communication. Team-orientation. Management of multiple projects simultaneously. Strong organization with attention to detail. Legible handwriting. Computer literacy. Minimum keyboarding/typing speed of 45 wpm.

Ability to educate patients and communicate instructions related to physician’s treatment plan.