Scribe (full time) | General Surgeons

Job Summary

The MA Scribe in the General Surgery clinic supports healthcare providers by preparing exam rooms, assisting patients, and accurately documenting clinical intake and patient history. Responsibilities include performing lab tests, conducting in-office diagnostics, and assisting during exams and procedures. The role also involves EHR management, handling variances or complaints, and maintaining inventory control to ensure clinic efficiency and safety.

Job Duties and Responsibilities

Patient Intake & Documentation of Clinical Care:

• Prepare exam rooms and assist patients in transitioning to the exam room.
• Prepare patients for age/gender-appropriate assessments.
• Document clinical intake, monitor patient interventions, and outcomes.
• Accurately and thoroughly document office visits and procedures as they are performed by the provider.
• Perform administrative tasks to assist with communication, referrals, authorizations, and EHR inbox processing under provider supervision.

Assist Healthcare Provider During Exams & Procedures:

• Aid the provider during examinations and procedures within the scope of practice, education, and training.
• Perform medical scribe duties, documenting patient examinations and procedures, including entering orders and referrals.

CLIA-Waived Lab Testing & Diagnostic Tests:

• Perform CLIA-waived lab tests, venipuncture, and capillary blood draws following regulations and quality measures.
• Conduct in-office diagnostic tests, such as EKGs, vision, and hearing screenings under direct supervision.

Medication Prior Authorizations & Vaccines:

• Manage medication prior authorizations with patient insurance companies.
• Administer various injections (subcutaneous, intramuscular, intradermal) under supervision.

EHR Clinical Inbox & Electronic Documentation:

• Process electronic documents, manage patient cases, and handle clinical inbox tasks, including refill requests and lab results.
• Provide transcription support as needed.

Online Incident Reporting:

• Report variances, near misses, or complaints regarding clinical care or customer service using the organization's incident reporting system.
• Promote patient safety, improve processes, and enhance patient satisfaction.

Inventory Control & Medical Supplies:

• Order medical supplies and monitor inventory per applicable guidelines.
• Suggest supply improvements to enhance care quality and safety.

Miscellaneous Duties:

• Monitor waiting room areas for safety and privacy.
• Respond to emergencies and notify appropriate staff.
• Relay non-urgent information to leadership (e.g., equipment issues, supply needs).

Job Requirements

Required Education:

• None

Required Licenses and/or Certifications:

• Basic Life Support (BLS)

Required Work Experience:

• Experience with computers and ability to document and communicate via office systems.

Required Knowledge, Skills, and Abilities:

• Exceptional customer service and communication skills.
• Ability to work closely with others and maintain a positive attitude.
• Strong organizational skills and task prioritization.
• Ability to work independently and multitask.
• Legible penmanship, punctuality, and preparedness.

Preferred Qualifications:

• MA, CNA, or EMT training.
• Medical office experience or medical terminology course completion.

Functional Demands

Population(s) Served:
All ages, genders, and demographic groups.

Physical Demands:
Fast-paced office setting requiring lifting (<35 lbs.), bending, standing, and reading small print.

Environmental Conditions:
Primarily indoors with occasional exposure to outdoor weather.

Organizational Expectations

• Represent the organization positively and professionally.
• Promote safety for patients and employees.
• Maintain compliance with policies and standards.
• Demonstrate excellent customer service consistent with organizational values.