Medical Scribe

Advocate Health and Hospitals Corporation • Rome, GA

12d • Onsite

About The Position

The Medical Scribe position is a part-time role within the Surgery: Orthopedics department. The primary function is to assist physicians by preparing and documenting medical records in real-time during patient visits using electronic medical record applications. This role involves anticipating physician needs, accurately transcribing patient encounters, preparing orders, and updating patient health information. The scribe will ensure all documentation is complete, accurate, and timely, adhering to policies and procedures, including HIPAA compliance.

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.
• 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

• May need successful completion of authorized medical scribe training course within 30 days of hire.

Responsibilities

• Prepares and assembles medical record documentation/chart for physician prior to patient visit.
• Obtains internal and external previous medical records and test results to anticipate physician needs for patient visits.
• 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

• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• 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

What This Job Offers

• Job Type: Part-time
• Career Level: Entry Level
• Education Level: High school or GED