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Midwest Vision Partners · 8 hours ago

Clinical Scribe II

United States

Full-time

Remote

Entry Level

2+ years exp

Midwest Vision Partners is seeking a Remote Clinical Scribe responsible for accurate documentation and summarization of ocular examinations while ensuring patient flow. The role involves real-time listening to physician encounters, documenting findings in the EMR, and facilitating communication between the physician and in-office staff.

Health CareMedicalWellness

Responsibilities

Listen to the encounter in real-time via a HIPAA-compliant audio or video connection (e.g., Zoom for Healthcare, EMR-integrated audio)

Correctly summarize and document what the physician verbalizes during an examination, including, but not limited to, proper charting of the examination

Document the encounter within the EMR under the provider's supervision, including:

Chief Complaint & HPI

Review of Systems

Exam findings (as dictated by provider or read from tech notes)

Assessment & Plan

Procedure documentation (e.g., injections, lasers)

Accurately bring Team Lead/Manager's attention to chart errors according to remote practice protocols

Prepare accurate eyeglass or contact lens prescriptions and/or medication prescriptions per protocol, prior to the physician's completion of the examination, when applicable

Complete the superbill in the EMR and Route Slip, and relay the next steps to the in-office support staff

Collect all pertinent information for upcoming procedures/surgeries, as protocol dictates

Know required components of examination for appropriate CPT coding to ensure all elements are accurately completed and documented accordingly

Understand Medicare and other common insurance requirements for quality reporting to help practice comply with payer requirements

Alert the physician to patient-related forms that need completion

Send appropriate forms, labs, and/or testing to the primary care physician and/or specialists, per protocol

Remain logged into the secure, live audio/video connection with the physician during the assigned clinic session, limiting time away, as documentation may be missed

Does not independently interpret imaging, enter orders, or communicate with patients

Work in a secure, private environment with no external recording, screenshots, or downloads of Protected Health Information (PHI)

Facilitate real-time communication between the physician and other in-office staff members (via secure internal messaging/chat) to minimize clinic flow disruptions and coordinate patient needs

Notify the physician of changes to the daily schedule, especially emergencies, via secure internal communication

Learn the personality and preferences of each physician, recognizing differences and abiding by them

Consistently and pro-actively perform any necessary documentation or administrative duties during any lull in clinic, making productive, wise use of time

Perform other administrative and documentation tasks, as required

Qualification

Ophthalmology experienceEMR documentationCPT coding knowledgeOphthalmic Scribe CertificationCustomer service skillsPrioritize tasksSpelling abilityCommunication skills