Medical Scribe

Smart Staffing Group • Syracuse, NY

26d • Onsite

About The Position

This role involves maintaining and performing administrative charting of clinical services provided to patients by a healthcare professional. The Medical Scribe will be responsible for thorough and accurate documentation of all encounter visits and procedures as they are being performed by the physician. This includes, but is not limited to, patient medical history, physical exams, procedures and treatments performed by healthcare professionals, and physician-dictated diagnoses, medications, and instructions. The scribe will also prepare referral letters under the direction of the provider, ensure accurate recording of clinical data and test results, and attend patient selection and multidisciplinary patient care committee meetings as assigned. Consultation with the RN Coordinator and/or Physician Committee Chair is required to ensure documentation accuracy and adequacy.

Requirements

• Bachelor's Degree or pertinent college level courses
• Three years of administrative/office management experience
• Proficient with EPIC EMR
• Comply with specific standards that apply to the legal and ethical requirements for preparing medical documents while being HIPAA compliant
• Proficient in EPIC EMR, typing, spelling, punctuation, grammar, and oral communication
• Excellent English composition skills required to generate professional, polished writing at a high rate of production
• Able to learn and use all functions of the EPIC EMR system
• Able to type quickly and accurately
• Comply with HIPAA confidentiality standards when accessing or communicating patient information
• Successfully pass pre-employment health clearance if working onsite

Responsibilities

• Maintain and perform administrative charting of clinical services provided to patients by a healthcare professional within the Department
• Thorough and accurate documentation of all encounter 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, Accurate and thoroughly scribed Physician-dictated diagnoses, medications and instructions for patient or family members
• Under direction of the provider, prepare accurate referral letters as requested by the provider.
• Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the electronic medical record and will always document that the note was scribed on behalf of Doctor
• Attend patient selection and other multidisciplinary patient care committee meetings as assigned
• Consult with the RN Coordinator and/or Physician Committee Chair to ensure accuracy and adequacy of documentation

What This Job Offers

• Career Level: Mid Level