Ophthalmic - Scribe

Eye Associates Of New Mexico•Albuquerque, NM

2d•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. This role requires collaboration with both front office and back-office staff, attention to detail in medical documentation, knowledge of ophthalmic terminology and procedures, and a commitment to continuous learning and professional growth. The scribe plays a critical role in enhancing provider efficiency, optimizing patient care, and contributing to the overall effectiveness of the clinic.

Requirements

High school diploma or equivalent required.
Certified Ophthalmic Assistant (COA) required or Certified Ophthalmic Technician (COT) required
OSC Certification required.
Sign off by MD/OD as meeting scribe requirements.
Strong verbal, written, grammar, and interpersonal communication skills.
Proficient typing skills i.e., touch typing or 40-50 WPM preferred.
Proficient in EMR systems and medical documentation.
Ability to learn and operate various ophthalmic and laboratory testing equipment.
Strong knowledge of ophthalmic anatomy, terminology, and ocular medications.
Familiarity with common ophthalmic procedures, including diagnostic testing (refraction, lensometry imaging), minor in-office procedures, and post-operative care.
Ability to complete patient exams, impressions, treatment or surgical plans, coding, and follow-up documentation.
Knowledge of ocular diseases and conditions across subspecialties (e.g., retina, cornea, glaucoma, neuro-ophthalmology, anterior segment).
High level of knowledge regarding Anti Vegf, biosimilar drugs and diagnosis eligibility (as needed for retina scribes).
High level of knowledge regarding injectable or topical treatments and diagnosis and eligibility (as needed for subspecialities (e.g., retina, cornea, glaucoma, anterior segment).
Understanding of genetic testing, research studies, and relevant clinical protocols.
Proficiency in contact lens workflows, formulary/non-formulary evaluations, and patient education.

Nice To Haves

High attention to detail and accuracy in documentation, coding, and EMR usage.
Strong communication skills with patients, providers, and team members.

Responsibilities

Maintains efficient clinic flow to optimize provider schedules and enhance patient care.
Supports team members during backlogs to ensure smooth operations.
Accompanies providers during patient visits, documenting encounters accurately in a structured, detailed format.
Completes exam documentation, including impressions, treatment or surgical plans, coding, and return-to-clinic notes prior to patient discharge.
Assists providers and staff in understanding chart notes to determine appropriate exams, testing, or procedures.
Documents patient history, examinations, assessments, diagnostic results, procedures, and treatment plans in compliance with CPT and ICD-10 coding standards.
Ensures medical necessity for treatments and procedures is clearly documented.
Efficiently uses EMR systems, maintaining and updating templates, macros, as required.
Prepares after-visit summaries, postoperative care instructions, and patient education materials.
Uploads and organizes postoperative notes, diagrams, and related documentation in patient records.
Monitors pending labs, imaging, and pathology results to support timely provider decision-making.
Orders and tracks laboratory, imaging, and pathology tests per provider guidance.
Supports prior authorization processes for medications and procedures.
Accurately completes FMLA and other medical documentation in compliance with requirements.
Assists staff and providers by interpreting chart notes, answering clinical questions, and ensuring patient care needs are met efficiently.
Serves as preceptor for in-clinic trainees
Eager to learn, adapt to evolving clinical workflows, and embrace new technologies.
Committed to continuous professional growth, skill development, and knowledge expansion.
Works collaboratively within the patient care team, adapting to individual MD/OD preferences while maintaining professional and respectful interactions.
Quickly adapts to new concepts, procedures, and clinic operations.
The annual completion of assigned Learning Management System (LMS) courses is mandatory.
Other duties as assigned.