Responsible for summarizing and transcribing medical information into electronic health records (EHR) during medical visits and procedures for physicians and midlevel providers. Must quickly achieve high proficiency and speed with EHR. Must keep up with a fast-paced, high volume environment of 40+ patient encounters per day. With training, ensures that documentation meets standards for insurance and billing. Coordinates letters to referring physicians. Primary goal is to increase the efficiency and productivity of the physician and alleviate the provider’s administrative burden.
The ability to listen, summarize, and type information is correctly is essential. Good judgment, organizational ability, initiative, attention to detail, and the ability to be self-motivated are especially important. Excellent skills in typing, spelling, punctuation, and grammar are required. Good attendance is an essential element of this job. Must be able to anticipate physician needs to facilitate the flow of clinic.
Supervisory Responsibilities: This job has no supervisory responsibilities
Education/Experience: Medical assisting diploma or 2 years of college. Experience with EHR in a clinical role preferred. Transcription, clinical assisting, or nursing experience may also be helpful. Completion of Certified Dermatology Technician course required within 90 days of hire, unless employee has current nursing license or certificate in medical assisting.
Essential Job Duties and Responsibilities:
Accurately and thoroughly document medical visits and procedures as they are being performed by the physician, including but not limited to:
o Patient medical history and physical exam,
o Procedures and treatments performed by healthcare professionals, including nurses and physician assistants,
o Patient education and explanations of risks and benefits,
o Physician-dictated diagnoses, prescriptions and instructions for patient or family members for self-care and follow-up
Prepare referral letters as directed by the physician. 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. Research contact information for referring physicians, coordinate referrals, prepare operative reports, 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.
Utilize medical coding training provided by the practice to assist provider in selecting medical codes consistent with the visit documentation.
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 Meaningful Use, 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.
Proofread and edit all the physician’s medical documents for accuracy, spelling, punctuation, and grammar.
Must be available whenever physician or provider is working. Saturdays, early mornings, late evenings may be required. Travel to satellite clinics may be required on a regular basis.
Qualifications 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.
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.
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.
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 be able to use the internet to access schedules, research information, etc. To perform this job successfully, an individual should be able to learn and use all functions of electronic medical record software and transcription software.
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.
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.
Must have the ability to hear dictated instructions. Must stand for long periods of time, sometimes more than 9 hours. Must walk from room to room and sit at a stool. Must hold a pen and write for long hours. Must use a keyboard to type and sit at a computer for extended period. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception and ability to adjust focus.
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