Scribe

SB Clinical Practice Management Plan • Lake Grove, NY

4d • $20 • Onsite

About The Position

SUMMARY: This position requires the incumbent to provide clerical and information technology support for a physician within the practice. This includes primary responsibility of the operation of the electronic health records and electronic dictation system.

Requirements

• High School Diploma/GED
• Proficient in typing, 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.
• Must be able to learn and use all functions of electronic medical record software and transcription software.
• Must accurately enter data into a database, search for information, send and receive email and attachments.
• Must be able to type words and numbers quickly and accurately.
• Must comply with HIPAA confidentiality standards when accessing or communicating patient information.
• Good judgment, organizational ability, initiative, attention to detail.
• Must be proficient in Microsoft Office Word and Excel

Nice To Haves

• 1 year of experience as Scribe or Medical Assistant (must have graduated from an MA program) or in a medical office.
• Scribe certification will be considered in lieu of experience or college coursework as related to position.
• Bachelor’s degree.
• Ability to type 50-60 words per minute.
• Bilingual

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.
• Identify 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.
• 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.
• 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.
• Proofread and edit all the physician's medical documents for accuracy, spelling, punctuation, and grammar.
• Additional duties as assigned.

What This Job Offers

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