Ophthalmic Scribe

Ophthalmic Scribe

Assists the ophthalmologist in clinic in delivery of the highest standards of patient care by following the policies and procedures of the clinic operation and physician direction.

Essential Duties and Responsibilities:

• Assists with patient flow through clinic by greeting and rooming patients, scribing and walking patients to appropriate department (front desk, technicians, and patient care coordinators) to complete patient visit.
• Treats each patient with respect by greeting them by name, introducing yourself, cleaning the slit lamp in front of the patient, and explaining what will happen during the exam.
• Documents patient exams in electronic health record, noting specifically the exam components, diagnoses, treatment plans, orders, and medications
• Provides patient and family counseling and education as needed.
• Communicates medication orders to pharmacy via e-prescribing and/or patient as needed.
• Ensures timely response to patient questions and concerns
• Reviews all chart notes and correspondence daily to ensure accuracy and completeness.
• Serves as liaison to referral sources; identifies and resolves concerns; promotes physician and services
• Travels with physician to various sites to ensure coordinated and effective patient care
• Participates in Patient Informed Consent process.
• Understands and respects boundaries with regard to surgery orders and e-prescribing.
• Scribes with other providers as assigned.
• Participates in trainings and meets requirements for MIPS, HIPAA compliance and Protected Health Information (PHI).
• Active participant in continuous improvements.
• Participates in all company wide initiatives.
• Performs related duties as assigned to ensure quality patient care
• Attends all trainings and meetings as requested.
• Open and willing to try new workflows and ideas and provide encouragement for the provider to try new workflows and ideas.
• Monitor provider schedules and communicate scheduling issues clearly to providers to help maintain a balanced schedule and reduce the amount of patient overbooking.
• Remains calm at all times and reports any issues to appropriate levels of management.
• Willingly accepts and completes any other task or requests that manager assigns beyond items specifically listed in job description.

ELECTRONIC HEALTH RECORDS (EHR) /ELECTRONIC PRACTIVE MANAGEMENT (EPM):

• Comprehensive knowledge of EHR system and ability to use it efficiently
• Knowledge of medical terminology
• Proficiency at pulling all necessary information from EHR and input exam findings into patient chart as physician is conducting exam; chart patient complaint additions, physician assessment and plan
• Know and insert billing codes into chart as per physician instruction
• Ability to find patient insurance and other information

CODING:

• Ensures detailed and accurate chart documentation to meet ICD-10 requirements.
• Ensures proper coding technique is used, i.e. proper linking of diagnosis to procedure. Reviews and edits patient chief complaint.
• Codes clinic services before bringing patient to check out and surgery services on a daily basis to ensure timely, accurate and complete processing of services

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 minimum knowledge, skill, and/or ability required.

Education and/or Experience Required:COA, COT or COMT, Bachelor’s degree (B.A.) from four year college or university, or two to three years related experience and/or training, or equivalent combination of education and experience. Keyboarding and computer knowledge required. Bipngual a plus.

REASONING ABILITY: Ability to define problems, collect data, establish facts and draw valid conclusions. Ability to interpret an extensive variety of instructions.

COMMUNICATION SKILLS:

• Accurately scribes exam details as dictated by provider
• Communicates in an open and concise manner
• Exhibits good verbal (1 to 1 and 1 to group) communication skills

INNOVATION: Develops creative ideas and innovative approaches to improve teamwork, workflow, clinic efficiencies, patient care/customer service and productivity.

DECISION MAKING:

• Recognizes when a system or process is not producing the desired results
• Determines the cause of problems before taking action
• Gathers relevant information before meeting/decision and taking action
• Systematically generates and evaluates alternatives before making a decision
• Thinks in a logical, disciplined manner
• Manages time efficiently
• Manages multiple assignments simultaneously

INTERPERSONAL AND TEAM:

• Brings questions and concerns to supervisor for discussion and resolution
• Limits interactions/conversations with provider to patient related activities
• Facilitates communication
• Solicits constructive and critical feedback for self development
• Develop relationships that establish a sense of openness, concern, confidence and trust
• Gains cooperation and action from team members
• Modifies style to be appropriate for each situation
• Solicits/listens actively to the opinions and suggestions of others
• Confronts people problems and resolves conflict

INITIATIVE:

• Takes responsibility for personal actions
• Achieves results on time with minimal overtime
• Develops work skills to enrich current job and/or accept additional responsibilities
• Actively seeks educational opportunities to enrich current job competencies
• Takes appropriate action as problems or opportunities arise
• Recognizes and acts upon opportunities for continuous improvement
• Volunteers to help others when a need is identified
• Responds to requests, suggestions and leadership from management willingly and openly
• Understand team members’ needs and requirements

LEADERSHIP:

• Creates an enthusiastic, positive work environment
• Promotes unified culture and systems with a focus on a positive patient experience
• Possesses a commitment to quality and excellence
• Sets a proper example for others to follow
• Sets priorities with a proper sense of importance
• Follows through on assignments to assure successful completion
• Balances big picture with day-to-day requirements and details
• Values diversity in culture, ethnic background, thought, etc.
• Maintains composure when dealing with emergencies and crises

CERTIFICATES, LICENSES, REGISTRATIONS: COA preferred or obtained by 6 months of employment

Work Environment: The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this job.

• The noise level is usually moderate
• Frequently exposed to moving mechanical parts
• Occasionally exposed to wet and/or humid conditions, toxic or caustic chemicals, risk of electrical shock and vibration
• Occasionally exposed to communicable diseases and medical preparations common to a clinic environment
• Travel to other SPEC offices required
• Work with all SPEC providers required