Medical Scribe

Job Description:

Job Title: Scribe

FLSA Status: Non-Exempt

Type: Part-time/Full-time

Department: Operations

Reports To: Chief Scribe

What is a Scribe? Joining ScribeAmerica's team as a Scribe will be one of the most impactful and rewarding experiences of your life. A Scribe is on the "front-line" of healthcare, serving as an integral member of the care team and acting as physician's personal efficiency partner. While a Scribe does not perform clinical work (e.g., does not touch patients, does not practice medicine), s/he is completely immersed in the healthcare ecosystem by standing elbow-to-elbow with a physician or nurses for 8+ hours each day. It's a once-in-a-lifetime professional experience that should not be missed by anyone who is considering a career in healthcare!At every shift, a Scribe works side by side with board-certified physicians to perform a variety of tasks: document patient encounters, locate lab/radiology results or prior medical records, and/or assist the physician with any number of his/her non-clinical responsibilities. A Scribe truly witnesses all of the action close up and first-hand: you will see what actually happens in the fast-paced environment of an emergency department, observe a wide variety of cases from trauma to pediatrics to the elderly, and develop lasting relationships with your fellow Scribes and your partnering physicians. Whether it's helping you gain entrance into medical/nursing school, giving you priceless advice and insight, or just leading by example as a consummate professional, your partnering physician will profoundly affect your future as a healthcare professional. Your Scribe experience-the people you meet, the relationships you develop, the encounters you witness- will change your life! Don't wait, apply to be a Scribe today!
ESSENTIAL FUNCTIONS:

Duties and Responsibilities

Chart in real-time as the provider assesses and examines the patient

Document the history, physical exam, assessment and plan, results, procedures, treatment, and physician consultations

Record provider-dictated diagnoses, prescriptions and instructions for patient follow-up

Locate and obtain past medical histories, previous charts, past results and studies

Transcribe ancillary test results and their interpretations

Check on the progress of labs, imaging studies, and other patient data

Retrieve and display current and past EKGs and imaging films (e.g. X-rays) for the provider to review and record provider's interpretation

Understand basic ICD-10 documentation requirements

Comply with all national and local PHI laws including in HIPAA and HITECH

Comply with all facility, department, company policies and procedures

Perform a variety of other non-clinical tasks specific to the local facility

Required Education and Pre-requisites

This position requires:

Exemplary work ethic and professionalism

Excellent verbal and written communications skills

Ability to adapt to individual site needs

Ability to multitask is high stress environments

Strong computer skills - technological savvy

A typing speed of 50+ WPM

Training

Upon hiring, the scribe is expected to successfully complete the following requirements:

Classroom training

Medicolegal documentation

Medical facility flow

Efficiency management

Medical terminology

Pathophysiology

Physical exam findings

PHI/HIPAA/HITECH

Evaluation and Management (E&M) billing basics

ICD-10 documentation requirements

Final exam

Clinical training

Initial competency assessment

Facility-specific training

Physical Demands
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 functions.

Must be able to stand for long periods of time

Frequently required to stand, walk, sit, use hands, handle documents, bend and stoop as needed, and reach with hands and arms

Required to use a keyboard and computer regularly

Position Type/Expected Hours of Work
This is a full-time or part-time position and hours of work and days vary Monday through Sunday depending on the facility contract and scribe hours needed.

Travel
Travel is expected occasionally for this position between local hospitals and medical facilities, as required by the particular scribe program.

Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

ScribeAmerica provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity and/or expression, national origin, age, disability, genetics, protected veteran status, or any other legally protected group status. In addition to federal law requirements, ScribeAmerica complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

ScribeAmerica expressly prohibits any form of workplace harassment based on race, color, religion, sex, sexual orientation, gender identity and/or expression, national origin, age, disability, genetics, protected veteran status, or any other legally protected group status. Improper interference with the ability of ScribeAmerica's employees to perform their job duties may result in discipline up to and including discharge.