Medical Scribe

CarePoint Health • Bayonne, NJ

9d

About The Position

The Medical Scribe supports physicians by providing real-time documentation and clerical assistance during patient visits. This role is designed to improve physician efficiency and productivity, allowing providers to focus more on patient care. Medical Scribes play a key role in managing medical records and ensuring accurate, timely documentation.

Requirements

• Ability to write routine reports and correspondence.
• Proficient in typing and good at spelling, punctuation, grammar, and oral communication.
• Must be able to listen to complex medical information and summarize in a clear, complete, and concise fashion.
• Excellent English composition skills required to generate professional, polished writing at a high rate of production.
• Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports.
• Translate medical abbreviations into their expanded forms.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Prepare and interpret charts and graphs.
• Ability to compute ratio and percent.
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge.
• Ability to refer to reference materials to solve problems.
• Ability to use all functions of electronic medical record software and transcription software.
• Ability to accurately enter data into a database, search for information, send and receive email and attachments.
• Must be proficient in Microsoft Word in order to prepare correspondence, medical reports, and other documents.
• Must be proficient in Microsoft Excel to prepare flowcharts and organize data.
• Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.

Nice To Haves

• Bilingual English/Spanish preferred

Responsibilities

• Accurately and thoroughly document medical 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.
• Patient education and explanations of risks and benefits.
• Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
• Prepare referral letters as directed by the physician
• Perform Dictation/faxing/phone calls and clerical tasks.
• Prepare referral letters as directed by the physician, via dictation or summary of the medical record.
• Ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached.
• Research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
• Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors. All addenda must be signed off by a physician.
• Ensure that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record. Alert physician when chart is incomplete.
• Must comply with specific standards that apply to the style of medical records and to the legal and ethical requirements for preparing medical documents and for keeping patient information confidential.
• Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.
• Assist in developing and maintaining systems to track patient follow up and compliance.
• Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into processes and procedures. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.

Benefits

• Competitive compensation based on experience and qualifications: When determining the compensation, several factors may be considered including, years of relevant experience, credentials, union contracts, education, and internal equity.
• Comprehensive health, dental, and vision insurance
• 401K, Retirement savings plan with employer contribution
• Generous Paid Time Off (PTO) and paid holidays
• Tuition Reimbursement
• Opportunities for professional growth, development, and continuing education
• Employee wellness programs and resources

What This Job Offers

• Job Type: Part-time
• Career Level: Entry Level
• Education Level: No Education Listed