Health Information Management Scribe

CAMC Health System•Charleston, WV

5d•Onsite

About The Position

The Health Information Management Scribe captures accurate, detailed documentation of patient encounters in the electronic health record (EHR) or by handwritten record. Scribes may not make independent decisions or translations when entering information into the medical record. The role supports physicians with EHR navigation and documentation, helps ensure critical documentation is available for accurate coding, and provides clerical support to nursing. The employee must demonstrate competency through initial orientation and ongoing competency validation to perform assigned tasks and additional duties independently. The employee must obtain or possess, by the end of the orientation period, the patient-group knowledge and skills needed for developmentally appropriate assessment, treatment, or care when the position involves direct patient contact. Common duties include maintaining required education records, providing positive customer service, complying with attendance and scheduling policies, participating in quality improvement, working cost-effectively, following organizational policies, and supporting the organization’s mission and strategic plan. This is a full-time regular position scheduled for days at the Cancer Center Building in Charleston, West Virginia.

Requirements

High school diploma or GED.
Two years of experience in a medical office, clinical, or hospital setting; formalized training in Medical Transcription, Medical Terminology, and/or Physiology may substitute for the two years of experience.
Demonstrate competency through initial orientation and ongoing competency validation.
For positions involving direct patient contact, possess or obtain by the end of the orientation period the knowledge and skills to provide developmentally appropriate care, including interpreting patient needs, understanding growth and development, and understanding the range of treatment needed.

Nice To Haves

Medical transcription experience is preferred.

Responsibilities

Assist the physician in navigating the EHR.
Respond to messages as directed by the physician.
Locate information for review, including previous notes, reports, test results, and lab results.
Enter information into the medical record as directed by the physician.
Research information as requested by the physician.
Record handwritten information using approved downtime procedures when necessary.
Assist the physician in ensuring critical documentation is available and recorded for accurate coding.
Set up Normals and templates for clinicians.
Assist new clinicians in efficient use of Dragon and Cerner.
Act as a liaison with Desktop Support to troubleshoot issues.
Order tests, blood work, or other patient services as directed by the physician and follow up as directed during the patient visit.
Support nursing with daily clerical duties.
Perform other duties as assigned.
Maintain and document all applicable required education.
Demonstrate positive customer service and co-worker relations.
Comply with the company's attendance policy.
Participate in departmental and institutional continuous quality improvement activities.
Perform work in a cost-effective manner and in accordance with departmental pay practices and scheduling policies, including overtime, shift work, and on-call situations.
Perform work in alignment with the organization's mission and strategic plan.
Follow applicable organizational and departmental policies and procedures.