Medical Assistant (Clinical Document Assistant) - Behavioral Health - PT - Day

Position Status:

Part time

Shift:

First Shift (Days - Less than 12 hours per shift) (United States of America)

Hours per week:

20

Job Information
Exemption Status: Non-Exempt

A Brief Overview
Provides high quality documentation of the medical record through supervision by nursing and physicians. 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 of the patient care team who uses acquired, clerical skills to assist in maintaining efficient workflow to ensure safe, quality care with a patient centered approach focusing on continuity of patient care and satisfaction. This role is designed to support the Physician through the management and completion of the admission, progress notes and discharge summary within the scope of their practice. Making independent clinical decisions is outside of the scope for this position, refer clinical questions to the provider or nurse.

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

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

• Enters information in EHR as directed by provider. Respond to various EHR messages as directed by the provider. Ensure that all orders entered are read back and confirmed to provider and entered as Pended. Assist the provider in navigating the EHR

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

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

• Responsible for the documentation of the patient’s progress notes, and discharge summary under the direction and supervision of the physician. Documents in patient and department records in a timely, accurate and concise manner according to department standards.

• Evaluates the patient’s progress towards achieving outcomes and provides information to the physician as requested.

• 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 Individual is required to review and agree to abide by the Scribe/Team Documentation Assistant Policy.

• Promotes a mutually respectful environment that encourages the exchange of ideas and supports the effectiveness of professional relationships and integrates ethics in all aspects of practice.

• Demonstrates advocacy in all roles and settings.

• Practices Diversity, Equity and Inclusion principles in their daily work by respecting others’ uniqueness, perspectives, backgrounds or beliefs.

• Communicates effectively in all areas of professional practice

• Understands the roles of the multidisciplinary team and is able to articulate their purpose and function within the department

• Demonstrates competence in documenting according to hospital policies, regulatory agencies, and accreditation standards.

• Coordinates care with consulting physicians.

• Commits to lifelong learning through critical thinking, self-reflection, and inquiry for personal growth and development.

• Demonstrates willingness to participate in process of evolutio