Medical Scribe

Eye Center of St. Augustine•Palatka, FL

18h

About The Position

The Medical Scribe accompanies the doctor during patient visits and documents interactions in real time in the electronic medical record (EMR), enabling clinicians to focus on patient care. The role documents patient history, diagnoses, treatment plans, and other medical information as directed by the assigned doctor. The scribe participates indirectly in patient care by working alongside a doctor or surgeon. The position combines clinical documentation and administrative support in a fast-paced clinical environment. Basic ophthalmic and optometric knowledge is expected to develop within the first 90 days, and advanced knowledge of proper coding procedures is expected to develop within the first six months of hire.

Requirements

High school diploma or equivalent.
Typing speed greater than 60 words per minute.
Advanced active listening skills, time-management skills, and strong attention to detail.
Strong communication and interpersonal skills.
Ability to work in a fast-paced clinical environment.
Maintain confidentiality and professionalism at all times.
Basic medical, ophthalmology, and optometry knowledge, with knowledge needs varying by doctor subspecialty and patient type.
Basic competency in ophthalmic and optometric exams, procedures, pharmacology, and terminology is expected to develop within the first 90 days of hire.
Advanced knowledge of proper coding procedures is expected to develop within the first six months of hire.

Nice To Haves

Prior experience with medical terminology and documentation.
Training in EMR software.

Responsibilities

Document patient history, physical exams, diagnoses, treatment plans, lab and imaging results, and prescriptions in real time during consultations.
Assist with EMR/EHR navigation, enter orders, update charts, and generate referral letters or prescriptions.
Review patient charts for completeness and accuracy and ensure documentation meets compliance standards, including HIPAA and audit requirements.
Assist with patient education about conditions as requested by the treating doctor or surgeon.
Maintain cleanliness and orderliness of exam rooms during the workday.
Follow practice procedures and protocols and comply with state and federal regulations.
Determine whether documentation supports E/M or Eye Code, match applicable ICD-10 codes, and code in-office procedures based on documentation.
Report inventory and supply needs to leadership in a timely manner.
Participate in daily team huddles and regularly scheduled meetings as required.
Report potential or suspected errors to a supervisor or Compliance Officer.
Complete additional tasks or projects as needed to support the team.
Maintain a cooperative, self-motivated, courteous, and professional attitude.