The Medical Scribe, working within a clinical practice, will assist physicians with their nonclinical duties. S/he will extemporaneously transcribe the patient’s medical record for the physician, assist the physician in retrieving old medical records, lab results, and radiology results. The Medical Scribe assists the provider with other clerical operations that would support his/her function and efficiency in non-clinical patient care.

Administrative
* Documents procedures, patient orders (laboratory tests, radiology tests, medications, etc.) performed by the provider.

* Maintains patient's workup by documenting all results into patient's charts.

* Obtains medical records (old and new) and test results.

* Documents all consultations/discussions with family and/or the patient’s private physician or the on-call physician.

* Completes patient’s chart by transcribing results of all labs, x-rays, and other evaluations.

* Lists all proper diagnoses as well as any discharge/follow up instructions and prescriptions, as dictated by the provider.

* Inputs billing codes (CPT and ICD) under the direct orders of the provider only.

* Notifies provider and medical assistant of what needs attention by processing documents into patient's chart.

* Responsible for scheduling appointment and assisting the medical assistant.

* Initiates prior authorizations; follow-up on prior-auth status and communicates status information with patient.

* Ensures billing is up to date by checking missing slips.

* Verifies all required orders are completed before patient comes in.

Compliance/Safety
* Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.

* Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.

* If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.

* Completes all company mandatory modules and required job-specific training in the specified time frame.

Education
High School Diploma or GED- Required

Certification & Licensures
NAHMG Clinic-Based Staff:
Fingerprint Clearance Card application number- Required upon hire

Fingerprint Clearance Card- Required within 90 days of hire

Experience
Previous experience and/or knowledge of medical techniques and or terminology- Required

Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.