Medical Scribe
Department/Care Stream: Health Care Delivery
Location: Oak Park Center
LIA Reporting Structure: Timecard Approver: Center Manager Primary: Center Manager Secondary: Regional Director Specialty Connect
Status: Full-time
Pay Range: $22.64-$29.43
FLSA: Non-Exempt
EEO-1: Administrative Support Workers
Organization Information
WellSpaces mission is "achieving regional health through high quality comprehensive care." We believe that everyone deserves to be seen, no matter who you are, where you come from, where you work or what place you call home. At WellSpace, we see you!
We are driven to serve the whole person through comprehensive, integrated care, spanning medical, dental, behavioral health, and supportive services across the region. We do this by building a team of exceptional colleagues who are dedicated to our mission and becoming part of the communities we serve.
As the regions largest Community Health System, WellSpace utilizes a Confluence Model to integrate an internal network of healthcare modalities, including Federally Qualified Health Centers (FQHC), Certified Community Behavioral Health Center (CCBHC), Drug Medi-Cal and Specialty Mental Health programs, Californias second largest 988 Suicide and Crisis Lifeline Center, an independent Risk Bearing Organization (WellSpace Nexus), and more into a seamless confluence of care.
To ensure the highest quality of care, WellSpace is accredited by the Joint Commission for Ambulatory Care, Behavioral Health and as a CCBHC. Further, it is certified by the Joint Commission as a Primary Care Medical Home and a Behavioral Health Home. WellSpaces crisis programs are accredited by the American Association of Suicidology and the International Council for Helplines.
Position Summary
Medical Scribes primary duties are to follow a physician through their work day and chart patient encounters in real-time using a medical offices Electronic Health Record system, and existing templates. Medical Scribes also generate referral letters for physicians, manage and sort medical documents within the EHR system, and assist with prescribing. Medical Scribes can be thought of as data care managers, enabling physicians, medical assistants, and nurses to focus on patient in-take and care during clinic hours. Medical scribes, by handling data management tasks for physicians in real-time, free the physician to increase patient contact time, give more thought to complex cases, better manage patient flow through the department, and increase productivity to see more patients. Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider.
Required Qualifications
High School graduate or equivalent.
Completed course work in medical transcription, medical terminology and electronic health record software.
Certified Medical Transcriptionist (CMT) status preferred.
Two (2) years experience as a medical scribe preferred OR equivalent combination of education and experience.
Strong organizational skills with attention to detail.
Excellent knowledge of English language rules.
Communicate clearly and concisely, both verbally and in writing.
Excellent listening skills including the ability to hear and understand dialects and various accents.
Ability to apply knowledge of medical terminology, anatomy and physiology.
Computer literacy, including Word and Excel and database software experience a plus with the ability to use various word processing equipment.
Able to translate orally given information into well-organized accurate electronic statements or formatted EHR fields.
Able to type 40 words per minute.
Ability to abide by standards of professional ethics and maintain confidentiality.
Bilingual in Spanish preferred; or other languages desirable.
Current CPR and first aid certificates or the willingness to be trained within the first ninety (90) days of employment required.
Essential Responsibilities
Must be trained in Epic software and other agency software. On the job training may be offered.
Responsible for entering all physician remarks and comments using Epic EHR program with regard to patient care: H&Ps, operative notes, therapeutic procedures, consultations, discharge summaries, etc.
Proofread all electronic charting for accuracy and completeness; verifies patient information for accuracy and completeness.
Transcribe electronic information to verify it is free of terminology, punctuation, grammatical, typographical errors and misinterpretations.
Identify inconsistencies and seek clarification from the dictating individual.
Format reports and correct document changes made by physicians following all HIPAA regulations.
Prioritize, verify reports for accuracy/neatness, and promptly deliver STAT reports.
File all transcribed electronic documents for physician review and signature.
Copy and distribute electronic documents as required.
Maintain daily log of transcribed electronic data and provide Medical Records Director with daily documentation, if required.
Understand medical legal implications and responsibilities related to the transcription of electronic patient medical records.
Utilize medical dictionaries, current Physicians Desk Reference, Agency Formulary, and other reference materials as needed.
Answer the phone in a professional and courteous manner, take messages, route calls to appropriate staff members.
Perform clerical tasks as needed by the physician including faxing, phone calls, and referral letters.
Maintain a good working relationship within the department and with other departments and physicians. Show kindness and compassion for patients and patients family or support team, in a professional manner at all times.
Support and maintain a culture of safety, quality and compliance with HIPAA.
Comply with all legal and ethical requirements for medical documentation.
Alert physician when medical record is incomplete or medical documentation contains mistakes or inconsistencies.
Collect, organize, and catalog data for physician quality reporting system and other quality initiatives to increase patient compliance and improve outcomes.
Document medical visits and procedures as they are being performed by the physician accurately and thoroughly.
Complete annual education requirements.
Maintain regulatory requirements.
Complete in-services and returns in a timely fashion.
Attend annual review and department in-services required staff meetings, read and return all monthly staff meeting minutes.
Represent the organization in a positive and professional manner.
Actively participate in performance improvement and continuous quality improvement (CQI) activties.
Comply with all organizational policies regarding ethical business practices.
Perform other duties as requested.
Benefits
Successful candidate will receive regionally competitive salary, above average health benefits at reduced costs, company paid life insurance & long-term disability insurance, additional voluntary retirement plan with company match and no vesting schedule requirement.
Paid bereavement and jury duty leave
11 paid holidays per year
Paid time off
Paid sick leave
Flexible Spending Program
Company paid malpractice insurance for all providers
Professional development hours offered annually
Physical Demands and Work Environment
The work environment is characteristic of a medical clinic environment. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this