Medical Scribe

Redding Rancheria•Redding, CA

48d•Onsite

About The Position

This position will be open until filled. The listed wage reflects the entry-level rate for this position. Compensation may be adjusted based on experience, education, and qualifications. The Redding Rancheria is seeking a Medical Scribe. The preferred schedule for this position is 4, 10 hour shifts. Medical Scribes are individuals trained in medical documentation who assist a provider throughout their shift. The primary goal is to increase the efficiency and productivity of the physician. It will be the responsibility of the Medical Scribe to annotate any dictated or written information for the treatment of patients following all local, state, and federal guidelines for documentation into the electronic health record system. The Medical Scribe will be responsible for clearly recording each patient's symptoms, history, physical exam, sending referrals, ordering labs, ordering x-rays, and documenting the diagnosis. This position will have no direct involvement in patient care, but has an interdepartmental role in assisting nursing and front office staff.

Requirements

One year of experience in a healthcare field preferred or minimum 2 year of college education with Medical Terminology, Anatomy, and Physiology coursework/degree.
Must be fingerprinted and pass background check.
Must pass pre-employment drug screening.
Indian preference.

Responsibilities

Assist the clinician with documentation of each patient’s medical chart during his or her visit.
Accompany the clinician into the patient examination area in order to transcribe a history and physical examination as given by the patient and physician.
Document any procedures performed by the clinician or nurses and printing the consent forms prior to the procedure, on the electronic medical chart.
Use various templates and documentation techniques available in the EHR system efficiently so individual encounters can be well documented, as well as accurately congregate data collected for statistical reports.
Transcribe any consultations or discussions with family members and/or the clinician.
Complete the patient’s chart by transcribing results of any labs, x-rays, or other evaluations, continuously checking on the progress of this data in order to get the patient’s workup complete so that the clinician is able to make his or her decisions regarding that patient.
List all proper diagnoses as well as any follow up instructions and prescriptions, as dictated by the clinician.
Order labs and order x-rays, with knowing how to add the patient to the x-ray schedule.
Transcribe referrals during the visit while sending it to the correct specialty.
Generate notes, excusal letters, and any other forms the clinician requires; in so being able to navigate the document library.
Schedule a patient for future visits.
Look up insurance, in assisting the front staff.
Aide in management of QIP measures.
Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.
Ensure medical record compliance by self-documentation attestation.
Other duties as assigned.