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Health Information Management - Medical Scribe

Company: CNY Family Care, LLP
Location: East Syracuse
Posted on: September 25, 2022

Job Description:

When you come to work for CNY Family Care, you join the best family practice in Onondaga County. Our commitment to service excellence sets us apart. Our Cornerstones: Patient-Centered Medical Home Excellence, Teamwork, Safety, Respect, and Professionalism, guide us as we provide care for our community.
As a part of those Cornerstones, it is especially important to us that we create a work environment where people feel welcomed, comfortable, valued for what they bring to the organization, and recognized for their contributions. It goes beyond salary and benefits. We work hard to develop an environment and culture that attracts top-quality talent. That is what sets CNY Family Care apart.
Job duties and responsibilities of a medical scribe include and are limited to the following:

Thorough and accurate documentation of all encounter visits and procedures as they are being performed by the physician, nurse practitioner, or physician assistant including but not limited to:

Patient HPI, medical history/ and physical exam
Procedures and treatments performed by healthcare professionals, including nurses and medical assistants
Accurate and thoroughly scribed qualified healthcare professionals-dictated diagnoses, medications, and instructions for patient or family members
Accurate and thoroughly scribed qualified healthcare professionals' orders
Under direction of the provider, prepare accurate referrals, que prescriptions

Medical scribe may spot mistakes or inconsistencies in medical documentation and check to correct the information to reduce errors. All addenda must be signed off by a physician, nurse practitioner, or physician assistant. Medical scribes ensure that all clinical data, lab or other test results, the interpretation of the results by the physician, are recorded accurately in the electronic medical record. Medical scribe must be proficient with Medent EMR and comply with specific standards that apply to the legal and ethical requirements for preparing medical documents while being HIPAA compliant. Medical scribe will always document that the note was scribed on behalf of Dr. "X".

Remain current/up to date on all Medent EMR updates, HIPAA and regulator/ compliance, billing, and coding. Quickly assimilate new knowledge into processes and procedures.

The requirements listed below are representative of the knowledge, skill, and/or ability required of a qualified candidate. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Language Skills - Medical scribe must be proficient in Medent EMR, typing, spelling, punctuation, grammar, and oral communication. Excellent English composition skills required to generate professional, polished writing at a high rate of production.
2. Understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately report. Translatemedical abbreviations into their expanded forms.
3. Reasoning Ability - Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to apply logic and draw conclusions based on knowledge. Must be able refer to reference materials to solve problems.
4. Computer Skills - To perform this job successfully, an individual should be able to learn and use all functions of the Medent EMR system.

We offer an incredibly competitive compensation and benefits package, 401K after six months with up to 4% matching, an additional annual discretionary profit-sharing contribution, as well as liberal paid time-off.
Health benefits available to all fulltime employees and coverage becomes effective the first of the month following your date of hire.
Vacation time is available for use after three months.
Tuition reimbursement is available for career-related education.
Job Requirements
Knowledge, Skills, and Requirements
Medent system experience highly preferred
Microsoft Office Products experienced knowledge
Ability to communicate effectively, both orally and in writing
High degree of professionalism and confidentiality required
Thorough knowledge of medical terminology, CPT, and ICD-10 coding and documentation guidelines
Must be meticulously detail-oriented, organized, and able to adapt to a growing organization

Education and Experience:
Accredited Record Technician or eligible (RHIT, RHIA), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS)
Practical Nurse (LPN) with a minimum of 5 years' experience in an appropriate health care setting. Working knowledge of ICD-9-CM, CPT & E & M coding conventions required
At least 2 years of electronic medical record experience required
Ability to type 60 + words per minute required
Associates or higher degree preferred

Work type: Fulltime, on site, one location
Reports to: Director of NursingPI192296528

Keywords: CNY Family Care, LLP, Syracuse , Health Information Management - Medical Scribe, Executive , East Syracuse, New York

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