Medical Scribe

POSITION SUMMARY: Under the general supervision of the RN Clinic Coordinator (RNCC) or Lead RN. The primary goal of the Medical Scribe is to make the increase efficiency and productivity of the medical provider they are working with and allows the provider to focus on what’s important, the patient. Scribes relate effectively with all health providers, nursing staff, other departments, and other medical scribes to ensure continuity of care; participates in all phases of education; patient advocacy, maintenance of records. Duties will include floating to other sites when needed for support. Maintain the standards consistent with the level of care set by Title 22.

ESSENTIAL JOB FUNCTIONS: The list that follows is not intended as a comprehensive list, but rather to provide a representative summary of the major duties and responsibilities. Incumbent(s) may not be required to perform all duties listed, and may be required to perform additional, position-specific tasks.

• Adhere to strict confidentiality and NVIH Policies and Procedures.
• Primary responsibility of the operation of the electronic health record system. Anticipating the need of the provider to facilitate the flow of visits is critical for incumbent’s success.
• Medical Scribes must be discreet, tactful, and modest in performance of duties so as not to distract medical staff rom patient care.
• Assist providers in maintaining medical documentation and throughout their shift with transcribing clinical notes, entering orders, and referrals under the direction from the providers.
• Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important.
• Document accurately the medical provider’s encounter with the patient and others present.
• List all diagnoses discussed in the visit, and the symptoms reported by the patient, as well as follow up instructions and prescriptions as dictated by the medical provider.
• Transcribe patient orders including laboratory tests, radiology tests, medications, etc.
• Document any procedures performed by the medical provider.
• Dictation/faxing/phone calls and clerical tasks. Medical Scribes may be asked to prepare referral letters as directed by the medical provider, via dictation or summary of the medical record. Medical Scribes ensure that all clinical data, lab or other tests results, and the interpretation of the results by the medical provider are recorded accurately in the medical record.
• Alert medical provider when 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. Spot mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.
• Attend training on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding. Quickly assimilate new knowledge into process and procedures.
• Medical Scribes proofread and edit all the documents they generate for accuracy, spelling, punctuation, and grammar.
• Travel to other locations for training, coverage, or other business needs as directed and per NVIH procedures.
• Other duties as assigned.

All NVIH employees are expected to:

• Provide the highest possible level of service to patients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the NVIH’s policies and procedures as they may from time to time be updated.

REQUIRED QUALIFICATIONS:

• High School Diploma or equivalent.
• Current CPR certification.
• Some college in healthcare or biology field preferred.
• Electronic Health Records experience preferred.
• Able to work collaboratively with multiple health professionals in a busy and complex environment using tact, diplomacy, and discipline.
• Working knowledge of medical terminology sufficient to communicate appropriately with patients, and healthcare professionals.
• Strong charting/documentation skills utilizing advanced computer skills.
• Commitment to excellence, high standards, and strong interpersonal skills
• Excellent written and oral communication skills, able to effectively relate via the telephone and in-person to serve the needs of clinic patients/clients/visitors in a manner that is efficient and productive.
• Versatility, flexibility, and a willingness to work within constantly changing priorities with enthusiasm as an innovative team player.
• Acute attention to detail.
• Must have reliable transportation to engage in regular attendance and travel between sites as necessary.

Native Preference. Northern Valley Indian Health provides Native Preference in hiring practices for qualified Native applicants, in accordance with its policy. NVIH is also an Equal Opportunity and At Will Employer.

• Medical, Dental, Vision coverage
• 14 Paid Company Holidays
• Generous PTO Package
• 401K Matching