Certified Medical Assistant: Scribe
Job description
Accurately and thoroughly documents medical visits and procedures as they are being performed by the physician, including but not limited to: patient medical history & physical exam; patient education and explanation of risks and benefits; physician dictated diagnoses, prescriptions and instructions for patient or family members for self-care or follow-up; preparation of documents as directed by the physician- Identifies mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors. All addenda must be signed off by a physician. Ensures that all clinical data, lab or other test results, the interpretation of the results by the physician are recorded accurately in the medical record.
- Alerts physician when chart is incomplete.
- Complies 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.
Well-qualified MA or LPN (Certification may be pending)
- Provides nursing care to patients and accepts delegation from assigned supervisor and/or provider in order to meet the needs of the patient/family
- Collects data and information to assist the clinical team and/or the provider in patient assessment and care planning which includes but is not limited to:
o Triaging patients
o Communicating through telephone encounters
o Reviewing past documents
o Reviewing hospital/clinical records
o Prioritizing patient assignments
o Completing patient assistance and prior authorizations for medications
- Delivers care in accordance with the patient care plan, as well as in accordance with policies and procedures of the office
- Performs duties as back up for starting IV for imaging department as needed
- Assists in setting patients up with holter monitors & event monitors – includes application of monitor and explanation of patient’s duties when wearing the monitor
- Possesses excellent communication skills and participates in teamwork
- Effectively and respectfully communicates with other departments of the office
- Demonstrates cardiac related knowledge and appropriately applies knowledge to patient care
- Demonstrate excellent communication skills (verbal and written) as well as computer/electronic medical record systems skills
- Exhibit an ability to adapt to unpredictable situations within the work setting
- Holds/maintains a current LPN license and maintain Basic Life Support (BLS)
- Independently completes assignments in a timely manner
Performs duties as alternative/substitute nurse for Coumadin clinic
Demonstrates the SEC Corporate Culture at all times with colleagues, providers, outside offices/vendors, patients and their family members. Consistently portrays a positive attitude; excels in individual role while creating a culture of teamwork and cooperation; puts the patient/family first and regularly seek opportunities for self-improvement as well as operational improvement.
Core Competencies
Approachability, Compassion, Customer Focus, Dealing with Ambiguity, Decision Quality, Ethics & Values, Integrity & Trust, Motivating Others, Peer Relationships, Drive for Results, Listening
Functional Competencies
Assertiveness, Comfort around Higher Management, Composure, Listening, Organizing, Problem Solving, Technical Learning, Time Management, Understanding Others
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