Clinical Documentation Specialist

JOB OVERVIEW: 

The Medical Scribe role assists a physician throughout their shift with medical documentation. The primary goal of a Medical Scribe is to increase the efficiency and the productivity of the physician they are working for. The Medical Scribe allows the doctor to focus on the evaluation, management, and treatment of patients at The Orthopaedic Institute. 

ESSENTIAL FUNCTIONS INCLUDE, BUT ARE NOT LIMITED TO: 

• 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
• Dictation/faxing/phone calls and clerical tasks. Medical Scribes are asked to prepare referral letters as directed by the physician, via dictation or summary of the medical record. Medical Scribe also ensure that letters are mailed or faxed on a daily basis to all physicians involved in a patient’s care, and with all copies of pertinent reports or tests attached. You may be asked to research contact information for referring physicians, coordinate referrals, prepare operative reports, make phone calls, and other clerical tasks as assigned.
• Medical Scribes also spot 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. Medical Scribes 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. Medical Scribes must 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.
• Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. You will assist in developing and maintaining systems to track patient follow up and compliance.
• 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. Medical Scribes proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
• Ensure all safety regulations are adhered to.
• Other duties as assigned

QUALIFICATIONS/LICENSE: 

CCMA or CNA preferred. CPR certified preferred

EDUCATION:

High School Diploma or equivalent

EXPERIENCE:

1-2 years of medical scribe experience preferred

SKILLS:

• Excellent customer service skills.
• Comfortable working in fast paced environment.
• Excellent communication skills, both verbal and written.
• Proficient with computer skills including experience with practice management software desired. 

PHYSICAL REQUIREMENTS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

• Specific vision requirements include the ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus.
• While performing the duties of this job, the employee is regularly required to talk and hear.
• Possess the ability to fulfill any office activities normally expected in a direct patient care role in a medical office setting.
• Frequently required to stand, walk, sit, use hands to feel, and reach with hand and arms.
• Occasionally lift and/or move over 25 pounds.
• Fine hand manipulation (keyboarding).
• Travel may be required to existing or new TOI locations.