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Job Information
Exemption Status: Non-Exempt

A Brief Overview
This position spends a high percentage of time performing medical transcription duties as a "real time" Documentation Assistant for a specific physician. Time is spent routing and processing documentation and delivering reports to physicians for review in a timely manner. Core responsibility is to capture accurate and detailed documentation of the patient encounter in a real time manner. Member uses acquired, office-based skills to assist physicians and nursing personnel to maintain smooth working order of the offices, continuity of patient care and client satisfaction.

Education Qualifications

• Successfully completed first semester in an accredited nursing program. Required or

• Successfully completed a medical assistant or patient care technician program. Required or

• A Certified Clinical Medical Assistant, Certified Medical Assistant, Registered Medical Assistant, Certified Nursing Assistant, or Emergency Medical Technician may be substituted for the educational requirement. Required

Experience Qualifications

• 1 year Transcription/scribe/MA or PCT experience Preferred

• Experience typing or transcribing conversations. Required

• Experience in a medical setting working with providers. Required

• Experience with medical terminology and procedures. Required

Skills and Abilities

• Conscientious regarding care of equipment, utilization of supplies and personal time.

• Knowledgeable of correct set-up and procedures to safely perform ear irrigation, monitor oxygen via mask and nasal cannula, assist with suture care and removal.

• Knowledgeable of and follows correct techniques in the ordering, collection, and labeling specimens; in assisting providers in clean or sterile procedures.

• Possess the ability to organize and prioritize assigned work duties and have a desire to interact with patients in a professional and empathetic manner.

Licenses and Certifications

• Active certification to practice in Kansas as either Certified Clinical Medical Assistant, Certified Medical Assistant, Registered Medical Assistant, Certified Nursing Assistant, or Emergency Medical Technician is required as a substitute for education qualifications. Required

What you will do

• All documentation assistant entries must contain an entry made by the provider that - Affirms the providers presence during the time the encounter was recorded -Verification that provider reviewed the information - Verification of the accuracy of the information - Provider authentication including date and time

• Assist the provider in navigating the EHR. Respond to various EHR messages as directed by the provider. Enter information into the EHR as directed by the provider. Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response. Ensure that all entries in the EHR by the Documentation Assistant are authenticated by the Documentation Assistant including date and time.

• Locate information for review (i.e. previous notes, reports, results, etc.). Obtains vital signs, medication list, allergies, simple patient history information accurately. Knowledgeable of correct set-up and procedures to safely perform ear irrigation, monitor oxygen via mask and nasal cannula, assist with suture care and removal.

• Receives telephone messages and appropriately relays these messages to the physicians and nurses. Assists with callbacks as indicated to deliver prompt, prioritized patient care (patient, pharmacies, insurance companies, etc.). Schedules consults and follow up appointments.

• Complete In basket work such as result notes at direction of provider, order information, and patient schedule.

• Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response.

• Obtain medication and procedure prior authorizations.

• Applies proper techniques with hand washing, instrument handling and care, care and cleaning of exam rooms and equipment and determination of when and how to use personal protective clothing/equipment.

• Assists with simple patient teaching: procedures, laboratory tests, medications, etc.

• Maintains exam rooms with necessary supplies and materials. Prepares list of supplies needed. Checks expiration dates.

• May assist with wound care and cast care.

• Assists with Code Blue events and transfers to hospital.

• Efficiently documents medical information using the appropriate electronic applications and/or forms.

Required for All Jobs

• Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health

• Performs other duties as assigned

Patient Facing Options

• Position is Patient Facing

Remote Work Guidelines

• Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.

• Stable access to electricity and a minimum of 25mb upload and internet speed.

• Dedicate full attention to the job duties and communication with others during working hours.

• Adhere to break and attendance schedules agreed upon with supervisor.

• Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.

Remote Work Capability

• On-Site; No Remote

Scope

• No Supervisory Responsibility

• No Budget Responsibility

Physical Demands

• Balancing: Occasionally 1-3 Hours

• Carrying: Occasionally 1-3 Hours

• Climbing (Ladders): Rarely less than 1 hour

• Climbing (Stairs): Rarely less than 1 hour

• Crawling: Rarely less than 1 hour

• Crouching: Occasionally 1-3 Hours

• Driving (Automatic): Rarely less than 1 hour

• Driving (Standard): Rarely less than 1 hour

• Eye/Hand/Foot Coordination: Frequently 3-5 Hours

• Feeling: Occasionally 1-3 Hours

• Grasping (Fine Motor): Frequently 3-5 Hours

• Grasping (Gross Hand): Occasionally 1-3 Hours

• Handling: Occasionally 1-3 Hours

• Hearing: Frequently 3-5 Hours

• Kneeling: Occasionally 1-3 Hours

• Lifting: Occasionally 1-3 Hours up to 25 lbs

• Operate Foot Controls: Rarely less than 1 hour

• Pulling: Occasionally 1-3 Hours up to 25 lbs

• Pushing: Occasionally 1-3 Hours up to 25 lbs

• Reaching (Forward): Occasionally 1-3 Hours up to 25 lbs

• Reaching (Overhead): Occasionally 1-3 Hours up to 25 lbs

• Repetitive Motions: Frequently 3-5 Hours

• Sitting: Frequently 3-5 Hours

• Standing: Frequently 3-5 Hours

• Stooping: Rarely less than 1 hour

• Talking: Occasionally 1-3 Hours

• Walking: Frequently 3-5 Hours

Working Conditions

• Burn: Rarely less than 1 hour

• Chemical: Rarely less than 1 hour

• Combative Patients: Occasionally 1-3 Hours

• Dusts: Rarely less than 1 hour

• Electrical: Rarely less than 1 hour

• Explosive: Rarely less than 1 hour

• Extreme Temperatures: Rarely less than 1 hour

• Infectious Diseases: Occasionally 1-3 Hours

• Mechanical: Rarely less than 1 hour

• Needle Stick: Occasionally 1-3 Hours

• Noise/Sounds: Occasionally 1-3 Hours

• Other Atmospheric Conditions: Rarely less than 1 hour

• Poor Ventilation, Fumes and/or Gases: Rarely less than 1 hour

• Radiant Energy: Rarely less than 1 hour

• Risk of Exposure to Blood and Body Fluids: Occasionally 1-3 Hours

• Risk of Exposure to Hazardous Drugs: Rarely less than 1 hour

• Hazards (other): Rarely less than 1 hour

• Vibration: Rarely less than 1 hour

• Wet and/or Humid: Rarely less than 1 hour

Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.

Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.