Medical Scribe - Cardiology

American Addiction Centers•Oshkosh, WI

1d•Onsite

About The Position

The Medical Scribe prepares and assembles medical record documentation for physicians, anticipating their needs by obtaining previous medical records and test results. The role involves entering the patient room with the physician/clinician to capture and transcribe medical record documentation in real time using electronic medical record applications, ensuring all documentation is complete and accurate. The scribe documents physician/clinician communication with patients, prepares orders (follow-up testing, lab, medication, consults/referrals), and documents correct follow-up instructions and service level. Additionally, the scribe assists in data entry, completes medical records for each encounter, updates patient history under physician direction, and prepares documentation for review. With proven competency, the scribe may also perform clinical functions such as patient rooming, obtaining vital signs, assisting with non-sterile procedures, scheduling appointments, and other EHR data entry.

Requirements

High School Graduate.
Typically requires 1 year of experience in medical assisting, medical transcription, emergency medical services, patient service and/or as a health care professional with demonstrated proficiency in medical terminology and technical spelling.
May need successful completion of authorized medical scribe training course within 30 days of hire.
Knowledge of medical terminology, including basic human anatomy and coding.
Demonstrates familiarity with medication names and medical procedures.
Knowledge of essential elements of documenting a provider-patient encounter, HIPAA compliance, and Centers for Medicare and Medicaid Services requirements.
Excellent communication and interpersonal skills.
Ability to maintain sensitivity and confidentiality for the patient while assisting physician.
Ability to develop rapport and maintain positive, professional relationships.
Requires adherence to all policies and procedures, including but not limited to standards for safety, patient service, attendance, punctuality, and personal appearance.
Proficient computer skills including: advanced keyboarding, above average typing speed, navigation within a windows operating system, and use of electronic mail with exposure to electronic medical records systems.
Ability to effectively multi-task, with excellent prioritization and organization skills.
Must have a high attention to detail and accuracy when documenting health information.
Ability to work effectively in a fast paced and stressful environment.
Must have ability to travel to various work locations.

Nice To Haves

Strong typing skills preferred.

Responsibilities

Prepares and assembles medical record documentation/chart for physician prior to patient visit.
Anticipates physician needs for patient visits by obtaining internal and external previous medical records and test results.
Ensures that all elements of documentation are complete and accurate.
Enters the patient room with the physician/clinician during patient visit to capture and transcribe medical record documentation in real time using electronic medical record applications.
Documents the physician/clinician's communication with the patient using appropriate medical terms and phrasing.
Prepares (pends) orders including follow-up testing, lab orders, medication orders, consults and/or referrals and the associated diagnosis to be connected with those orders.
Documents the correct follow-up instructions and level of service designation based on the physician/clinician's direction.
Assists in data entry from devices or other sources.
Completes medical records for each encounter ensuring accurate and timely documentation.
Under physician/clinician direction, updates patient history and other pertinent health information in the patient record.
Prepares and sends all documentation for review and approval.
With proven competency, may perform clinical functions such as prepare and room patient for exam, obtain vital signs and document/update pertinent health information, assist the physician/clinician with non-sterile procedures, schedule appointments and referrals to other facilities or services, and perform other data entry into the EHR.

Benefits

Comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work.
Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training.
Premium pay such as shift, on call, and more based on a teammate's job.
Incentive pay for select positions.
Opportunity for annual increases based on performance.
Paid Time Off programs.
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability.
Flexible Spending Accounts for eligible health care and dependent care expenses.
Family benefits such as adoption assistance and paid parental leave.
Defined contribution retirement plans with employer match and other financial wellness programs.
Educational Assistance Program.