Clinical Ops Support - Medical Scribe Lead

Clinical Ops Support - Medical Scribe Lead

Position Summary: 

The primary responsibilities of a Lead Scribe overseeing operations of their assigned scribe program sites, which includes but is not limited to scheduling, recruitment, training, emergency coverage, and quality assurance. Scribe Leads will operate under the supervision of their assigned Scribe Supervisor. They will act as our main liaison between Scribe Upper Management and the clinic sites. Additionally, all duties of a Medical Scribe will apply. 

The primary responsibilities of the Medical Scribe are to document all relevant dictated or written information for the treatment of patients. Medical Scribes will be responsible for clearly recording each patient's symptoms, history, physical exam, and documenting the diagnosis as well as treatment plans abiding by all local, state, and federal guidelines for documentation into electronic medical records. The Medical Scribe is not a direct patient care role.

Essential Functions of the Job:

Lead Functions:

• Creating, publishing, and managing the schedules for their assigned locations. Any shift changes and swaps will also need to be managed by Lead Scribe. Scribe Supervisors will oversee this and assist only as needed.
• Assist their Scribe Supervisor in performing recruitment activities which will include screening/interviewing applicants and keeping in communication Scribe Upper Management when there is a hiring need.
• Assist in classroom training and clinical training of scribes including backfill and scribe for new providers at their assigned locations.
• Assist their Scribe Supervisor in the creation of training material, if necessary.
• Find alternative coverage for open shifts and/or provide emergency shift coverage, if necessary. Scribe Supervisors will oversee this and assist only as needed.
• Attend CQI and other site-specific staff meetings on behalf of the their assigned scribe team(s).
• Report conducts and behavioral issues of the scribes to the Scribe Supervisors on a regular basis.
• Remain a key contact for the CSM to address any site specific issues with the oversight of the assigned Scribe Supervisor.
• Reporting to the Scribe Manager and Scribe Leads operational issues and concerns with goal for continual improvement and enhancement of the Scribe Program

Scribe Functions:

• The Medical Scribe accompanies the clinician into the patient examination area in order to transcribe a patient history and physical examination.
• Under the direction of the clinician, transcribes patient orders, including laboratory tests, radiology tests, referrals, etc.
• Documents any procedures performed by the clinician or nurses.
• Transcribes any consultations and/or discussions with family.
• Lists all proper diagnoses as well as any follow-up instructions as dictated by the clinician.
• Assists the clinician in reviewing and transcribing prior internal and external medical records.
• At the end of the patient encounter or shift, provides the scribed documentation for the clinician to review to ensure all events were recorded accurately.

• Make recommendations for continued process improvement to the Scribe Manager.

Prohibited Scope of Service:

• Patient Care:  The scribe is not directly involved with patient care; however, he/she may be asked to give patient paperwork during visit or discuss discharge instructions with a patient. The scribes' direct interaction with patients is limited.
• General Documentation: A scribe cannot document any of his/her personal objective findings or be involved in any of the medical decision-making. A scribe cannot act independently; instead, he/she must simply document the physician's dictation and or/activities during the visit.

Additional Duties and Responsibilities:

• Maintains confidentiality of all patient and employee information and adheres to all HIPAA requirements.
• Informs supervisor of matters of general interest and problem areas determined or discovered.
• Attends all SYHealth mandatory meetings and other meetings as requested.
• Demonstrates openness to organizational and/or departmental changes.
• Personally, commits to advancing a customer request or correcting customer service problems and does so undefensively.
• Remains engaged in their work.
• Understands and adheres to all SYHealth policies and procedures.
• Adheres to and consistently demonstrates SYHealth's Core Values of Respect, Excellence, Empowerment, and Integrity.

Job Requirements

Education Required (Minimum level of education):

• High School diploma or equivalent is required.
• A strong academic history required.
• Successful completion of any relevant additional college-level courses is preferred, i.e. medical terminology, anatomy, physiology, etc.

Experience Required (Minimum level of experience): 

• Completion of the SYH Scribe Training program is required - may be completed on hire.
• Strong written and verbal skills in the English language are required.
• Proficiency in the Spanish language is strongly preferred.
• Strong computer skills are required.
• 50+wpm typing speed required.
• 6 months to 1 year of Medical Scribe experience strongly preferred.
• Candidates with experience in the medical field are preferred.

Certifications/Licenses Preferred/Required:

• ACMSS certification is preferred.

Verbal and Written Skills Required to Perform the Job:

• Strong written and verbal skills in the English language are required.
• Proficiency in the Spanish language is strongly preferred.

Physical Activities:   

• Considerable keyboarding
• Long periods of sitting, walking, and standing.
• Local driving and travel may be required.

Working Traits:        

• Organization
• Ability to take constructive criticism well
• Ability to multi-task
• Ability to manage and motivate a team
• Strong leadership skills

Technical Knowledge and Skills Required to Perform the Job:

• Advanced computer skills with a minimum of 50wpm typing speed is required.
• Experience with EHR's, especially NextGen, is preferred.

Equipment Used:

• A laptop will be provided.

Working Conditions and Physical Requirements:   

• May need to work weekends and extended hours.

Universal Requirements

• Pre-employment requirements include I-9, health screening (including PPD), positive background and reference check results, complete application, and new hire documentation completion. 

Upon Hire Requirements

HIPAA/Compliance

1. Maintain privacy of all patient, employee and volunteer information and access such information only on a need to know basis for business purposes.
2. Comply with all regulations regarding corporate integrity and security obligations. Report unethical, fraudulent or unlawful behavior or activity.

OSHA Compliance

• Comply with all regulations and required schedules regarding OSHA training.

Health Screening/PPD Compliance

• Required health screening/PPD to be performed annually.

Policies and Procedures Compliance

• Responsible for following all SYHealth policies and procedures.

Meal Period Compliance (Non-exempt employees only.)

• Punch out before end of 5 hours of work from the start of shift for meal periods.

Sexual Harassment Training

• Comply with all regulations and required schedules regarding sexual harassment training.

Customer Service and Diversity and Inclusion Training

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment.  Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.