Job Description

Internal Medicine practice is looking for a full-time remote (work from home) self-motivated clinical staff with prior virtual scribing experience from any primary care outpatient setting. The ideal candidate is required to have familiarity with medical terminology, medical coding, and commonly prescribed medications in the primary care setting; must also have fast but accurate typing skills; and excellent English listening and writing skills. 

Work hours are 7:30 AM to 5 PM US CST Monday through Thursday and Friday. The position requires pre- and post-work preparations. Work hours are subject to the provider’s schedule and needs.

**Duties and Responsibilities:**

• Pre-encounter activities 72 hours before patients’ scheduled visit: 

* Review the Schedule to determine charts to prep for upcoming appointments
* Identify, update, and obtain missing information in a patient's chart before their scheduled visit.
* Obtain records from multiple hospital and outpatient facilities as needed
* Skim the last two office encounter notes and review for: 
* Referrals
* a) Was it submitted?
* b) Did the patient schedule or go to this appt?
* c) Do we have the note? - Request/Obtain Note from specialist/facility
* New Medications
* a) Did the patient pick this prescription up?
* b) Has the medication list been updated with the changes from the last visit?
* Procedure Orders (Imaging studies, Stool cards, other Labs, etc.)
* a) Did the patient complete the order? 
* b) Do we have the result?
* Prepare the shell of the progress note for the patients' upcoming encounters. This includes
* a) Virtually pulling the patient's chart
* b) Insert appropriate customs forms, Memo contents, and flow sheets
* c) Review Consult Reports and Update Consult Reports Flowsheet
* Use the appropriate template and pull in flowsheets
* Review Consultant/Specialist Notes and Imaging Studies and complete appropriate flowsheets
* Recent Hospitalizations: 
* a) Pull in the Transition of Care flow sheet if this was completed.
* b) Ensure hospitalization records have been requested and in the chart. 
* c) Order the records if they are not. 
* Review labs and Update lab flowsheet 
* Send requisitions for labs and imaging studies as requested by providers before the scheduled visit 
* Review Imaging Reports and Update imaging flowsheet (if any)
* Update Chronic Pain Management Flow Sheet (if applicable)
* Adding basic procedure codes CPT, CITI, HCPCS & ICD-10
* Prepare draft to visit Superbills and Provider Orders as instructed

• Intra Encounter activities: 

* In real-time, summarize and document conversations between the provider and patient in the progress note
* Transcribe dictated notes from the provider (both during and post-encounter)
* Pull data from various parts of the chart into the encounter as directed by the provider (both during and post-encounter)
* Input appropriate diagnosis and service codes using EMR and other available databases
* Organize and format encounter progress notes per SOAP note structure
* Update Health Alerts at the end of the encounter in the EMR
* Follow patient confidentiality guidelines and legal documentation requirements including the Health Insurance Portability and Accountability Act (HIPAA). 
* Post Encounter activities
* Adhere to all documentation compliance standards.
* Update the Quality Measures Database flow sheet in Google Sheets
* Develop and maintain a mutually respectful working relationship with all providers.
* Be Available for provider concerns and questions and always be ready to assist in improving documentation
* Tracking of referrals, Imaging requisitions, etc. - to ensure results are received in patient charts
* Data entry into and updating patient flowsheets
* Perform other duties assigned by the providers.

**Job Requirements and Qualifications:** 

* Be a Registered Nurse or Allied Healthcare professional (education can be replaced with comparable medical scribing experience).
* Have at least 1 year of Receiving Medical Scribing experience in an outpatient clinic setting
* Certification as a medical scribe is a plus, but not required
* Must have IT infrastructure to execute contract

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