Scribe (COA)

Eye Associates Of New Mexico•Albuquerque, NM

1d•Onsite

About The Position

The Ophthalmic Scribe supports providers and the patient care team by accurately documenting clinical encounters, maintaining efficient clinic workflows, and ensuring comprehensive patient records. The role collaborates with front-office and back-office staff and requires attention to detail in medical documentation, knowledge of ophthalmic terminology and procedures, and commitment to ongoing learning and professional growth. The scribe helps improve provider efficiency, patient care, and the overall effectiveness of the clinic. The position is full-time, Monday through Friday, and performed on-site at the Harper location. Responsibilities include accompanying providers during visits, recording structured and accurate encounter documentation, completing exam notes and follow-up information before patients leave, supporting clinic flow, and helping staff interpret chart notes. The scribe documents histories, examinations, assessments, diagnostic results, procedures, and treatment plans; prepares patient instructions and education materials; and maintains patient records and EMR templates. The role also supports test orders and tracking, prior authorizations, medical forms, and trainee precepting. Assigned Learning Management System courses must be completed annually by November 30; failure to complete training may result in disciplinary action, up to termination.

Requirements

High school diploma or equivalent.
Certified Ophthalmic Assistant (COA) or Certified Ophthalmic Technician (COT) certification.
OSC Certification.
Sign-off by an MD/OD confirming that the employee meets scribe requirements.
Strong verbal, written, grammar, and interpersonal communication skills.
Proficiency in medical documentation and EMR systems.
Ability to learn and operate ophthalmic and laboratory testing equipment.
High attention to detail and accuracy in documentation, coding, and EMR use.
Knowledge of ophthalmic anatomy, terminology, ocular medications, diseases, and conditions across subspecialties.
Familiarity with ophthalmic diagnostic testing, minor in-office procedures, and postoperative care.
Ability to complete patient exams, impressions, treatment or surgical plans, coding, and follow-up documentation.
Ability to see, speak, listen, and develop written materials.
Ability to lift, push, and pull patients and equipment using proper body mechanics; stand and walk and use fine motor skills for extended periods.
Ability to work under stressful conditions and maintain schedule flexibility for emergencies.

Nice To Haves

Proficient typing skills, such as touch typing or 40–50 words per minute.
Knowledge of anti-VEGF and biosimilar drugs and diagnosis eligibility, as needed for retina scribes.
Knowledge of injectable or topical treatments and diagnosis eligibility for relevant subspecialties.
Understanding of genetic testing, research studies, and relevant clinical protocols.
Proficiency in contact lens workflows, formulary and non-formulary evaluations, and patient education.

Responsibilities

Maintain efficient clinic flow to optimize provider schedules and support patient care.
Support team members during backlogs to ensure smooth clinic operations.
Accompany providers during patient visits and accurately document encounters in a structured, detailed format.
Complete exam documentation, including impressions, treatment or surgical plans, coding, and return-to-clinic notes before patient discharge.
Help providers and staff interpret chart notes to determine appropriate exams, testing, or procedures.
Document patient histories, examinations, assessments, diagnostic results, procedures, and treatment plans in compliance with CPT and ICD-10 coding standards.
Clearly document medical necessity for treatments and procedures.
Use EMR systems efficiently and maintain or update templates and macros as required.
Prepare after-visit summaries, postoperative care instructions, and patient education materials.
Upload and organize postoperative notes, diagrams, and related documentation in patient records.
Monitor pending laboratory, imaging, and pathology results to support timely provider decision-making.
Order and track laboratory, imaging, and pathology tests according to provider guidance.
Support prior authorization processes for medications and procedures.
Complete FMLA and other medical documentation accurately and in compliance with requirements.
Assist staff and providers by interpreting chart notes, answering clinical questions, and ensuring patient care needs are met efficiently.
Serve as a preceptor for in-clinic trainees.
Complete assigned Learning Management System courses annually by November 30.
Adapt to evolving clinical workflows and technologies, collaborate respectfully with the patient care team, and pursue ongoing professional growth.
Perform other duties as assigned.