Medical Scribe

4 weeks ago

Troy, Michigan, United States Wayne Health Services Inc Full time
About Us:

Wayne Health Services Inc is a leading healthcare provider, serving one million patients and their families annually. We advance medical knowledge, technologies, and practices, and develop and educate the next generation of exceptional healthcare professionals.

Job Summary:
The Medical Scribe is responsible for accurately documenting the patient-provider encounter. This is an in-person scribe position in an inpatient (hospital) setting, and in-person or virtual outpatient setting.

Key Responsibilities:
  • Accompany the clinical provider during patient examinations to transcribe clinician examinations/evaluations, medications, diagnosis(s), and treatment team discussions into the Electronic Medical Record and clinician progress notes in real time as needed by the Physician.
  • Contact outside Providers to obtain collateral information to use in treatment and discharge planning, scheduling aftercare appointments as needed, in addition to notifying schools about patients' hospital admissions.
  • Assist facilitating phone calls between those involved in treatment and with insurance companies for reviews and grievances.
  • Have a knowledge-base of DSM and its usage.
  • General knowledge of substance abuse issues.
  • Knowledge of age-specific populations.
  • Ability to address cultural diversity and specific patient/family issues.
  • Maintains competence in identified universal core and critical competencies.
  • Attend treatment team meetings to capture patient information.
  • Actively assists attending physician in the scribing of patient notes.
  • Display excellence in customer service skills, returning all phone calls from internal staff members and external customers (i.e. medical advocate, schools, referral sources, etc.) within 24 hours.
  • Assist the Provider in navigating the Electronic Health Record (EHR)/Chart Serve as a point of contact and coordinate phone calls between physician and families, insurance companies and other providers in addition to checking messages for clinician throughout the day.
  • Locate information for review (i.e., previous notes, reports, test results, and laboratory results); Enter information into the chart/EHR as directed by the Provider.
  • Research information as requested by the Provider. Actively assists attending physician in the scribing of patient notes.
  • Accompany clinical provider during patient examinations/evaluations to transcribe examinations/evaluations and other orders to the Electronic Medical Record in real time as needed by the Physician.
  • Records diagnoses and assist in preparing discharge and/or follow-up instructions as dictated by the clinical provider.
  • Verifies the chart as needed for an appropriate coding level to ensure it has been documented correctly for the designated ICD-9 and CPT code.
  • Checking messages for Physicians throughout the day.
Requirements:
  • 2-4 years of undergraduate education with emphasis in behavioral health or pre-medical studies required.
  • 2 years experience working in a behavioral health environment preferred.
Skills and Abilities:
  • Must have a passion for medicine, psychology, or social work and a desire to assist patients with Behavioral Health concerns.
  • Ability to learn and appropriately apply basic medical terminologies and techniques taught and used on the job.
  • Strong written and verbal communication skills.
  • Ability to actively listen.
  • Ability to observe and to draft a narrative account of events accurately and cogently, in grammatically-correct English.
  • Ability to spell proofread and edit written text.
  • Keyboard proficiency.
  • Ability to operate a personal computer and related software applications.
  • Strong attention to detail.
  • Ability to work in a dynamic, highly-stressful environment that routinely involves exposure to highly-sensitive personal behavioral health/medical issues.
  • Ability to be adaptable and be willing to take constructive criticism.
  • Ability to coordinate multiple projects and patients.
  • Ability to prioritize.
  • Ability to problem solve under pressure.
  • Ability to communicate and interact professionally with others.
  • Understanding of and commitment to appropriate protection of confidential patient information.
  • Commitment to high professional ethical standards.
Safety Requirements:
  • Compliance with Department Health and Safety policies and procedures.
Working Conditions/Schedule:
  • 40-hour work week, hours and days to be determined by the business needs of the department. Additional Hours may be required.

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