Clinical Information Assistant/Scribe

SUMMARY 

The Clinical Information Assistant/Scribe assists Orthopedic Physicians as assigned with various administrative aspects of patient care in the Orthopedic Clinics at Orthopaedic Institute for Children’s downtown campus.  The Clinical Information Assistant will work in close association with medical assistants, residents and attending physicians and will be part of the clinical care team.

DUTIES AND RESPONSIBILITIES

• Documentation of history and physical findings in the electronic medical record.
• Follow-up of laboratory and x-ray results, and paging consults.
• Assists in patient admission, transfers or discharges.
• Assists in "chart auditing" both in real-time and retrospectively, which includes reviewing physicians' charts and procedure notes to ensure completeness, sending incomplete charts back to physicians.
• Performs other duties and requested or assigned.

PERFORMANCE STANDARDS AND SUCCESS INDICATORS

• Ability to perform under pressure, frequent interruptions and distractions.
• Ability to handle confidential material while protecting its strict confidentiality.
• Ability to proofread very detailed materials and monitor work accurately.
• Strong interpersonal skills to effectively and diplomatically interact with others. 
• Ability to speak clearly and distinctly using appropriate vocabulary and grammar to obtain and convey information. 
• Skill in working independently and following through on assignments with minimal supervision. 
• Ability to maintain equanimity in the face of resistance, indifference or hostility.
• Ability to organize and track multiple records and requests and follow through in a timely manner. 
• Ability to establish and maintain cooperative working relationships with co-workers, faculty, residents, students, University representatives, patients and the public.

QUALIFICATIONS

• Regionally accredited Bachelor’s degree in the science related field.
• Prior scribe experience required.
• Detailed knowledge of medical terminology and ability to distinguish different exams and medical diagnoses required.
• Demonstrated excellent verbal and written communication skills.
• Knowledge and skill in using various computer programs such as Word, Excel, PowerPoint, Outlook email, and basic database software.
• Knowledge of E/M codes and the level of documentation necessary for reach billing level preferred.  Cerner and EPIC EMR experience preferred.

Other Requirement:

• Willingness to work a flexible schedule which includes evenings and weekends.

Complexity:

Ability to perform highly detailed work with sustained attention and ware while providing/obtaining information on numerous inquiries is paramount to success in this position.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.