Internal Scribe/Clinical Assistant

Job Summary: 

Completes patient medical chart in real time as the provider assesses and examines the patient by facilitating patient flow and ensuring an accurate and complete medical record for each patient using an Electronic Medical Records (EMR) system. 

Job Tasks and Responsibilities: 

Accompany physician via zoom into the patient examination room to transcribe a history and physical exam, and document accurately the physician’s encounter with the patient and others present. 

Review prior medical records to obtain past medical history information and prior labs, ECGs and radiographic studies for comparison. 

Transcribe patient orders and all ancillary test results and their interpretations, including any lab tests, imaging tests, ECGs, radiology tests, medications, etc. 

Document any procedures performed by the physician. 

Accurately record provider’s consultations with other health care professionals, patients, and family members 

List all proper diagnoses and symptoms as well as follow up instructions and prescriptions as dictated by the physician. 

Understanding billing codes to help increase a provider’s charting efficiency. 

Document procedures and treatments performed by providers. 

Check on the progress of x-rays and other patient evaluation data. 

Record provider-dictated diagnoses, prescriptions and instructions for patient discharge and/or follow-up. 

Prep all MRM charts in EMR, as well as creating weekly documents for MRM to review before locking notes. 

Work collectively with MRM’s Executive Assistant on any projects requiring clinical input. 

Fill into Executive Assistant role when current EA is on vacation. 

Communicate via email with attorney’s if necessary for patient care. 

Skills: 

Understands medical terminology. 

Recognition of physical exam process and ability to record exam details. 

Computer proficiency and ability to quickly learn new applications. 

Hands on knowledge and use of medical EMR systems, ability to use eClinicalWorks EMR would be a significant asset. 

Legible handwriting and ability to accurately record information. 

Organizational skills with focus on tracking patient care and improving patient flow. 

Professional demeanor and recognition of privacy considerations for patients and families. 

Experience with Zoom, Microsoft Word/Excel/Office/Publisher/PowerPoint, Dropbox, Google Docs, and Outlook. 

Must be patient and become proficient in deciphering MRM’s handwriting. 

Qualifications: 

Education: College Degree - Biology, Health Sciences, Sports Medicine or a related field. 

Wishing to pursue a career in a medical related field as a PA, NP, MD or DO. 

Any experience as a Medical Scribe preferred, but not required. 

Environmental/Working Conditions: 

Normal office environment
(in Freehold and Princeton on days with office hours) 

Occasional overtime may be required depending on patient volume. 

Job Type:  Full-time 

Benefits:   

401K 

Dental Insurance 

Health Insurance 

Vision Insurance 

Health Savings Account 

Paid time off