The Medical Scribe is primarily responsible for documenting the patient history, physical examination, family, social, and past medical history as dictated by the Practitioner (Physician and/or mid-level Provider). The Medical Scribe will be responsible for clearly documenting all proper diagnoses and symptoms, as well as follow-up instructions and prescriptions into the Electronic Health Record (EHR) system as dictated by the Practitioner.
ESSENTIAL JOB FUNCTIONS:
• Document patient history: including any illness, review of systems, past medical and surgeries, family and social histories,
medications and allergies, as dictated by the practitioner.
• Document all proper diagnoses and symptoms in addition to follow-up instructions and prescriptions as dictated by the
• Document any physical examination findings and procedures performed by the practitioner.
• Document results of laboratory and radiographic studies as dictated by the practitioner.
• Document the correct time of patient-care related activities, including practitioner-to-practitioner communication, family
communication, and re-examination of the patient
• Navigate through Electronic Health Record system to project patient health records as requested by practitioner.
• Assign appropriate ICD10-CM, CPT, and other codes to patient encounters as needed.
• Performs other job duties as required by manager/supervisor.
• Completion of a high school diploma or equivalent.
• Must be proficient in using computers.
• Typing speed of 50+ WPM.
• Prior experience with an Electronic Health Record system is preferred.
• Excellent verbal and written communication skills.
• Experience with Microsoft Office (Word, Excel, PowerPoint) and Outlook.
• Detail-oriented and problem-solving skills.
• Ability to take direction and to follow instructions.
• Ability to multi-task, organize and prioritize work.
• Knowledge of medical terminology, anatomy, pathophysiology, pharmacology, CPT, ICD-10-CM or clinical documentation
• Prior customer service experience preferred.
• Prior experience in a medical field is a plus.
• Must be able to fluently speak, read and write English.
• Must be able to fluently speak Cantonese and/or Mandarin.
• Fluent in other languages are an asset.
This is an FLSA Non-exempt position.
This is not an OSHA high-risk position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).