Medical Assistant/Scribe

Role and Responsibilities:

• Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
• Greeting patients and preparing them for physical examination.
• Screens patients for appropriate information.
• The MA/ Scribe will also be responsible for maintaining exam rooms with necessary supplies and materials. Ensures cleanliness.
• Prepares equipment and aids physician during treatment, examination and testing of patients.
• Accompany provider in room during patient visit. Scribe document in Athena to include: history of present illness, review of systems, physical exam findings, diagnostic assessment and plan of care.
• Assist Clinician document through patient medical history and physical exam.
• Enter orders for procedures or labs as directed by the provider.
• Educates patient / family about diagnostic procedures, medications, nutrition and maintenance of health and wellness.
• Enter billing information as determined by the type of office visit.
• Document results of laboratory and radiographic studies as discussed by provider.
• Coordinate with clinicians to manage multiple patients and solve problems under pressure.
• Provides general care to patients which may include administering prescribed medications and treatments.
• The MA/ Scribes will also be skilled to 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.
• MA/ 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 proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
• MA/ 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.
• MA/ Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. The MA/Scribe will assist in developing and maintaining logs to track patients and follow up on compliance.
• MA/ Scribe with attend training with training specialist team and Litmus on diverse subjects such as Athena, legal, HIPAA and regulatory compliance, and billing.

Skills:

• Language Skills – The ability to write routine reports and correspondence. MA/ Scribes must be proficient in typing and good at 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.
• Translate medical abbreviations into their expanded forms.
• Computer Skills – To perform this job successfully, an individual should 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 proficient in Athena in order to prepare correspondence, medical reports, and other documents.
• Other Skills and Abilities – Must be able to type words and numbers quickly and accurately; must comply with HIPAA confidentiality standards when accessing or communicating patient information.
• Physical Demands – While performing the duties of this Job, a MA/ Scribe is regularly required to stand; sit; walk; use hands to type, write with a pen, finger, handle, or feel; reach with hands and arms and talk or hear. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

Qualifications and Education Requirements:

• High school diploma or equivalent.
• Proof of satisfactory completion of an approved medical assistant program or nursing assistant program; or
• One (1) year of experience in a medical related field.
• Registered and Certified Medical Assistants must maintain current RMA/CMA certification.
• Medical Assistants must maintain current RMA/CMA certification.
• Current CPR certification

Additional Notes

This job description is not intended to be all-inclusive, and employee will also perform other reasonable related business duties as assigned by supervisor.

This organization reserves the right to revise or change job duties and responsibilities as the need arises. This job description does not constitute a written or implied contract of employment_.