Full job description
- Need to have knowledge how to do vitals, tests, and also administration of vaccines
- Accompany physician into the patient examination room in order to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present.
- List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician.
- Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
- Document any procedures performed by the physician.
- Be pleasant while greeting patients and visitors.
- Detail to HIPAA privacy, should be aware of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy, Security and Breach Notification Rules.
- Maintain professional appearance and conduct at all times.
- Adhere to employer work practices.
- Establish and maintain effective working relationships with physicians, staff and managements.
- Effectively cope with typical job stress.
- Document work processes as required.
- Must complete all notes by the end of shift unless medical provider grants more time to finish or some external force prevents timely completion of these tasks (ex. patient did not provide necessary documentation, neither the scribe manager nor the head biller can provide accurate codes for a new procedure, there is a software issue, electricity goes out, etc.)
- Must have good experience dealing with the HEDIS which is a measure performance on important dimensions of care and service.
- Provider may refuse to grant more time if they feel scribe had sufficient time and/or information to complete notes on the same day. If a provider or the scribe manager determine that a scribe is requesting extra time too often, they can initiate disciplinary action at their discretion.
- Perform other duties as assigned.
- Provide online copies of transcribed documents to physicians or other providers for review and signature, making corrections or changes as noted
- Familiarity with proper grammar, spelling and sentence structure as well as medical jargon and abbreviations for accuracy
- Work with transcription equipment that can include speech recognition equipment, word processing, and computer software
- Maintain strict adherence to patient confidentiality according to provider standards and government regulations
- Examining documents for missing information.
- Assigning CPT, HCPCS, ICD-10-CM and ASA codes.
- Assigning APC and DRG codes.
- Ensuring documents are grammatically correct and free from typing errors.
- Performing chart audits.
- Ensuring compliance with medical coding policies and guidelines.
Skills:
- Medical terminology.
- Recognition of physical exam process and ability to record exam details.
- Computer proficiency and ability to quickly learn new applications.
- Legible handwriting and ability to accurately record information.
- Organizational skills with focus on tracking patient care and improving patient flow.
- Professional demeanor and recognition of privacy considerations for patients and families.
Other Requirements:
- Ability to multi-task efficiently and effectively.
- Must be able to act calmly and effectively in a busy or stressful situation.
- Ability to communicate effectively in the English language in person, by phone and in writing. 4. Requires adherence to all policies and procedures
Job Type: Full-time
Pay: From $10.00 per hour
Schedule:
- 8 hour shift
- Monday to Friday
Work Location: In person