Scribe

Job Locations US-NY-East Setauket
ID
2022-2219
Category
Administrative/Clerical
Department
ORTHOPAEDICS
Type
Per Diem

Overview

Scribe - Stony Brook Orthopaedic Associates, UFPC

Location: East Setauket, NY

Schedule: Per Diem

Days/Hours: As needed

Responsibilities

SUMMARY: This position requires the incumbent to provide clerical and information technology support for a physician within the practice. This includes primary responsibility of the operation of the electronic health records and electronic dictation system. 

 

Job Duties & Essential Functions:

  • 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.
  • Identify 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.
  • Attend trainings on diverse subjects such as information technology, legal, HIPAA 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.
  • Additional duties as assigned.

Qualifications

Required Education & Qualifications:

  • High School Diploma/GED
  • Proficient in typing, 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.
  • Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports.
  • Must 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 able to type words and numbers quickly and accurately.
  • Must comply with HIPAA confidentiality standards when accessing or communicating patient information.
  • Good judgment, organizational ability, initiative, attention to detail.
  • Must be proficient in Microsoft Office Word and Excel

 Preferred Qualifications:

  • 1 year of experience as Scribe or Medical Assistant (must have graduated from an MA program) or in a medical office. Scribe certification will be considered in lieu of experience or college coursework as related to position.
  • Bachelor’s degree.
  • Ability to type 50-60 words per minute.
  • Bilingual

 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. While performing the duties of this job, the employee is regularly required to communicate with patients, staff and medical providers. The employee must be able to exchange accurate information in these situations. This position is largely sedentary and requires the employee to remain stationary for a majority of the day. The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of CPMP.

 

In accordance with the New York State Department of Health (DOH) order that all hospitals and nursing homes “continuously require all personnel to be fully vaccinated against COVID-19,” Candidates who are not already vaccinated must obtain the first dose of the vaccine within three (3) calendar days of acceptance of conditional job offer and must obtain any subsequent doses in accordance with the vaccine protocol. The order also includes those who may be affiliated with or interact with employees of a hospital or nursing home. The order allows for limited medical exemptions with reasonable accommodations, consistent with applicable law.

 

CPMP provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity or expression, or any other legally protected status. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall and transfer, leaves of absence, compensation and training.

CPMP expressly prohibits any form of workplace harassment based on race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, gender identity, or any other legally protected status. Improper interference with the ability of CPMP’s employees to perform their job duties may result in discipline up to and including discharge.

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