Medical Scribe at RWJBarnabas Health in Bridgewater, New Jersey

Job Description:

Location:
Advanced Neurology Center, 1200 route 22 East, Bridgewater Township, NJ 08807

A Medical Scribe preforms all clerical and information technology functions for a physician in a medical office setting and assists the physician throughout their shift. This includes primary responsibility of the operation of the electronic health records and electronic dictation system.

DUTIES AND RESPONSIBILITIES:

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

* Prepare referral letters as directed by the physician

* Dictation/faxing/phone calls and clerical tasks.

* Prepare referral letters as directed by the physician, via dictation or summary of the medical record.

* Spot checking for mistakes or inconsistencies in medical documentation and check to correct the information in order to reduce errors.

* 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.

* Collect, organize and catalog data for physician quality reporting system and other quality improvement efforts and format for submission.

* Assist in developing and maintaining systems to track patient follow up and compliance.

* Attend trainings on diverse subjects such as information technology, legal, HIPAA and regulatory compliance, billing and coding.

* Proofread and edit all the physician s medical documents for accuracy, spelling, punctuation, and grammar.

Education and Experience:

* Bachelor s degree in healthcare field preferred; High School Diploma or GED required

* Two years of experience as a medical scribe in a medical office setting preferred

* Medical Assistant Certification from AAMA, AMT, NHA or NCCT preferred

* Translate medical abbreviations into their expanded forms.

* Excellent computer skills

* Strong attention to detail and accuracy

Knowledge, Skills and Abilities:

* Strong understanding of medical terminology, anatomy and physiology, diagnostic procedures, pharmacology, and treatment assessments to the extent required to understand and accurately transcribe dictated reports.

* Ability to work independently and show good judgment

* Strong oral and written communication skills are essential

PHYSICAL DEMANDS:

* Individuals must be able to meet established specific physical requirements of the job including sitting at a desk or meeting table, reaching, lifting, pulling, bending, stooping, twisting, standing and walking

Working Conditions:

* Exposure to blood borne pathogens

* Normal medical office environment.

RWJBarnabas Health is an Equal Opportunity Employer

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