Scribe Opportunities in Sells, AZ

Full Time

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The Medical Scribe performs all clerical and information technology functions for a physician in a clinic setting. This includes primary responsibility of the operation of the electronic health record and electronic dictation system. The scribe must be able to anticipate physician needs and facilitate the patient flow. The scribe must be discreet, tactful, and modest in performance of duties so as not to distract medical
staff from patient care. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are a must in this role. Adaptability, sincerity, and good attendance is also
an important element of this job. Must be responsible with a passion for healthcare and learning.

Primary Functions

Responsible for accurately and thoroughly documenting 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
• Preparation of referral letters as directed by the physician

Medical Scribes collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission. Medical Scribes assist in developing and maintaining systems to track patient follow up and compliance.

Medical Scribes attend training 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.

• 
  Take dictation using shorthand, a stenotype machine, or headsets and transcribing

• Return dictated reports in printed or electronic form for physician's review, signature, and corrections and for inclusion in patients' medical records.

o Prepare referral letters as directed by the physician, via dictation or summary of the medical record.

o 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.

o Additional duties may include researching contact information for referring physicians, coordinating referrals, preparing operative reports, making phone calls, and other clerical tasks as assigned.

• Review and edit transcribed reports or dictated material for spelling, grammar, clarity, consistency, and proper medical terminology.

o Responsible for looking for inconsistencies in medical documentation and ensuring that those are corrected. All addenda must be signed off by a physician.

Medical Scribes ensure that all clinical data, lab or other test results, and the interpretation of those results by the physician are recorded accurately in the medical record. Responsible for alerting the physician when the 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.

• Transcribe dictation for a variety of medical reports, such as patient histories, physical examinations, emergency room visits, operations, chart reviews, consultation, or discharge summaries.
• Distinguish between homonyms and recognize inconsistencies and mistakes in medical terms,

• Translate medical jargon and abbreviations into their expanded forms to ensure the accuracy of patient and health care facility records.
• Produce medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
• Identify mistakes in reports and check with doctors to obtain the correct information.
• Perform data entry and data retrieval services, providing data for inclusion in medical

• Set up and maintain medical files and databases, including records such as x-ray, lab, and procedure reports, medical histories, diagnostic workups, admission and discharge summaries, and clinical resumes.
• Receive patients, schedule appointments, and maintain patient records.
• Answer inquiries concerning the progress of medical cases, within the limits of

• Decide which information should be included or excluded in reports.
• Actively looking for ways to help people.
• Bringing others together and trying to reconcile differences.
• Responsible for developing and maintaining positive, professional, collaborative relationships with clients and ensuring customer satisfaction.
• Ensures annual competencies are met.

Experience Required:

Experience:

1 + years’ experience as a Medical Scribe in the ER environment (preferred, not
required)

Education:

College degree in related field, or current enrollment in a 4-year program in related
field

License/ Certifications: None

Knowledge, Skills, Abilities and Other Qualifications

• Ability to work independently, be attentive to detail, and maintain a positive attitude (Manage your emotional reactions to situations and people-self management is more than resisting explosive or

• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
• Strong organizational and interpersonal skills.
• Ability to determine appropriate course of action in more complex situations.
• Ability to complete work assignments accurately and in a timely manner.
• Ability to communicate effectively, both orally and in writing.
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner.
• Minimum typing speed of 65 WPM

Language Skills –

The ability to write routine reports and correspondence. Medical 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. Handwriting must
be clear and legible.

• 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.

Mathematical
Skills – Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Prepare and interpret charts and graphs. Ability to compute ratio and percent.

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 Microsoft Word in order to prepare correspondence, medical reports, and other documents. Must use Microsoft Excel to prepare flowcharts and organize data. Must use the internet to access schedules, research information, etc.

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.

Additional information:

Qualified applicants will undergo approximately 120 hours of initial training specific to Emergency Department and clinical settings,
upon hire.

Work
Environment

Physical demands:

While performing the duties of this Job, a Medical 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. The Medical Scribe is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.

The Medical Scribe must regularly lift and /or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.

Mental demands:

There are a number of deadlines associated with this position. The employee must be able to handle frequent interruptions and must also multi-task and interact
with a wider variety of people on various and, at times, complicated issues. Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Ability to refer to reference materials to solve problems.

Equal Opportunity Employer/ Vet/ Disability
American Indian applicants receive preference in employment and training incident to such employment.