Medical Scribe

Hudson River Healthcare - Brentwood, NY (30+ days ago)3.6

Hudson River HealthCare provides the highest quality comprehensive primary, preventive, and behavioral health services to all who seek it, regardless of insurance status and ability to pay, especially for the underserved and vulnerable. Hudson River Health Center (“HRHCare”) is a Federally Qualified, Non-For-Profit network of 27 community and migrant health centers located in Peekskill, Beacon, Poughkeepsie, Amenia, Dover Plains, Pine Plains, Middletown, New Paltz, Goshen, Greenport, Haverstraw, Spring Valley, Nyack, Monticello, Walden and Yonkers, Amityville, South Hampton, Wyandanch, Shirley, Patchogue, Brentwood and Riverhead. Annually, we serve over 150,000 patients through well over 650,000 visits throughout a ten county region in New York State.

HRHCare is currently seeking an experienced and knowledgeable Medical Scribe to assist our healthcare team with documenting patient medical records in Brentwood.

Performs all clerical and information technology functions for a physician in a primary care setting, including primary responsibility for the operation of electronic health records and electronic dictation systems. Must be able to anticipate physician needs to facilitate the flow of clinic. Provide the highest quality customer service to patients. Adheres to practice protocols and processes. Effectively manage the volume of work without allowing quality to be compromised. Primary goal is to increase the efficiency and productivity of the physician. This position will have some involvement in direct patient care. Must be discreet, tactful, and unobtrusive in performance of duties so as not to distract physician or other care team members from patient care. Good attendance is an important element of this job.

Minimum Education/Experience Requirement

Minimum of a two-year degree, or two years or more experience in a medical office.
Experience with use of Electronic Health Record (HER).
Preferred Education

Bachelor’s Degree
Certification as Medical Scribe Professional (CMSP)
Medical coding training or certification
Experience with use of E-Clinical Works (ECW) HER.
Essential Duties and Job Responsibilities

Accurately and thoroughly document 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
Prepare referrals, Diagnostic imaging and labs as directed by the physician
Ensure that results of labs and diagnostic imaging are mailed to patients as directed by physician.
Make phone calls, and other clerical tasks as assigned.
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.
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.
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.
Collect, organize and catalog data for Physician Quality Reporting System and other quality improvement efforts and format for submission.
Assist in developing and maintaining systems to track patient follow up and compliance.
Attend trainings on diverse subjects such as information technology, legal and regulatory compliance, billing and coding.
Quickly assimilate new knowledge into processes and procedures.
Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
Must be available whenever physician is working. Saturdays, early mornings, late evenings may be required.
Travel to multiple sites may be required on a regular basis.

Strong Work Ethic
Displays Integrity
Good Judgment
Mission Driven
Demonstrates Initiative
Strong & Effective Communicator verbally and written
Adaptable and Versatile
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Language Skills

Ability to write routine reports and correspondence.
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.
Reasoning Ability

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.
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.
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

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee 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 employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
The employee 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.
We offer a competitive benefits package, which includes medical, dental, Life and AD&D insurance, ongoing training opportunities and a wellness program.

Interested candidates please submit your resume.