Medical Scribe

WELLSPACE HEALTH • Sacramento, CA

33d • $23 - $29 • Onsite

About The Position

Medical Scribe's primary duties are to follow a physician through their work day and chart patient encounters in real-time using a medical office's Electronic Health Record system, and existing templates. Medical Scribes also generate referral letters for physicians, manage and sort medical documents within the EHR system, and assist with prescribing. Medical Scribes can be thought of as data care managers, enabling physicians, medical assistants, and nurses to focus on patient in-take and care during clinic hours. Medical scribes, by handling data management tasks for physicians in real-time, free the physician to increase patient contact time, give more thought to complex cases, better manage patient flow through the department, and increase productivity to see more patients. Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider.

Requirements

• High School graduate or equivalent.
• Completed course work in medical transcription, medical terminology and electronic health record software.
• Two (2) years' experience as a medical scribe preferred OR equivalent combination of education and experience.
• Strong organizational skills with attention to detail.
• Excellent knowledge of English language rules.
• Communicate clearly and concisely, both verbally and in writing.
• Excellent listening skills including the ability to hear and understand dialects and various accents.
• Ability to apply knowledge of medical terminology, anatomy and physiology.
• Computer literacy, including Word and Excel and database software experience a plus with the ability to use various word processing equipment.
• Able to translate orally given information into well-organized accurate electronic statements or formatted EHR fields.
• Able to type 40 words per minute.
• Ability to abide by standards of professional ethics and maintain confidentiality.
• Current CPR and first aid certificates or the willingness to be trained within the first ninety (90) days of employment required.

Nice To Haves

• Certified Medical Transcriptionist (CMT) status preferred.
• Bilingual in Spanish preferred; or other languages desirable.

Responsibilities

• Must be trained in Epic software and other agency software. On the job training may be offered.
• Responsible for entering all physician remarks and comments using Epic EHR program with regard to patient care: H&Ps, operative notes, therapeutic procedures, consultations, discharge summaries, etc.
• Proofread all electronic charting for accuracy and completeness; verifies patient information for accuracy and completeness.
• Transcribe electronic information to verify it is free of terminology, punctuation, grammatical, typographical errors and misinterpretations.
• Identify inconsistencies and seek clarification from the dictating individual.
• Format reports and correct document changes made by physicians following all HIPAA regulations.
• Prioritize, verify reports for accuracy/neatness, and promptly deliver STAT reports.
• File all transcribed electronic documents for physician review and signature.
• Copy and distribute electronic documents as required.
• Maintain daily log of transcribed electronic data and provide Medical Records Director with daily documentation, if required.
• Understand medical legal implications and responsibilities related to the transcription of electronic patient medical records.
• Utilize medical dictionaries, current Physician's Desk Reference, Agency Formulary, and other reference materials as needed.
• Answer the phone in a professional and courteous manner, take messages, route calls to appropriate staff members.
• Perform clerical tasks as needed by the physician including faxing, phone calls, and referral letters.
• Maintain a good working relationship within the department and with other departments and physicians.
• Show kindness and compassion for patients and patient's family or support team, in a professional manner at all times.
• Support and maintain a culture of safety, quality and compliance with HIPAA.
• Comply with all legal and ethical requirements for medical documentation.
• Alert physician when medical record is incomplete or medical documentation contains mistakes or inconsistencies.
• Collect, organize, and catalog data for physician quality reporting system and other quality initiatives to increase patient compliance and improve outcomes.
• Document medical visits and procedures as they are being performed by the physician accurately and thoroughly.
• Complete annual education requirements.
• Maintain regulatory requirements.
• Complete in-services and returns in a timely fashion.
• Attend annual review and department in-services required staff meetings, read and return all monthly staff meeting minutes.
• Represent the organization in a positive and professional manner.
• Actively participate in performance improvement and continuous quality improvement (CQI) activties.
• Comply with all organizational policies regarding ethical business practices.
• Perform other duties as requested.

Benefits

• Successful candidate will receive regionally competitive salary, above average health benefits at reduced costs, company paid life insurance & long-term disability insurance, additional voluntary retirement plan with company match and no vesting schedule requirement.
• Paid bereavement and jury duty leave
• 11 paid holidays per year
• Paid time off
• Paid sick leave
• Flexible Spending Program
• Company paid malpractice insurance for all providers
• Professional development hours offered annually

What This Job Offers

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