Scribe

JOB TITILE: SCRIBE

STATUS: AT-WILL/NON-EXEMPT

JOB SUMMARY

Reporting to the Directors of Clinical Leadership and Clinical Operations, or the District Manager, the Scribe provides essential documentation and administrative support to doctors and the clinical team to ensure accurate and efficient patient care. This role is responsible for recording doctor-patient interactions in real time, maintaining complete and accurate medical records within the electronic health record (EHR) system, and assisting with clinical coordination tasks. The Scribe contributes to the smooth operation of the clinic by anticipating provider needs, supporting workflow efficiency, and maintaining strict compliance with confidentiality and HIPAA standards.

ESSENTIAL FUNCTIONS

Clinical Documentation & Support

• Accurately documents doctor dictation, patient histories, assessments, treatment plans, procedures, and follow-up instructions into the EHR system in real time.
• Lists all proper diagnoses, symptoms, orders, and prescriptions as directed by the doctor.
• Transcribes patient orders for laboratory tests, imaging, medications, and referrals.
• Assists in preparing charts, reviewing patient medical histories, and confirming information prior to examinations.

Patient Interaction & Workflow Coordination

• Accompanies doctors into patient examination rooms to document encounters and assist with efficient visit flow.
• Ensures the doctor’s schedule and workflow are optimized by tracking patient progress and organizing follow-up tasks.
• Assists with triage and answers patient questions within the scope of the role; refers medical inquiries directly to the doctor as appropriate. This potentially involves a high volume of patient phone calls. 
• Ability to multi-task and anticipate the doctor’s needs in a busy clinic setting.

Clinic & Administrative Support

• Assists with preparing exam rooms, equipment, and instruments as needed.
• Supports and assists with procedures such as lesion removals, injections, and chalazion treatments as directed by the doctor.
• Posts exams and procedures to the billing ledger and supports documentation for accurate charge capture.
• Assists with filing, sorting, and organizing medical documents within the EHR system.
• Collaborates with technicians, doctors, and administrative staff to maintain efficient clinic operations.

Compliance & Professionalism

• Adheres to all HIPAA, OSHA, and company confidentiality standards.
• Maintains accuracy and integrity in documentation and data entry.
• Demonstrates professionalism, attention to detail, and composure in fast-paced clinical environments.
• Communicates clearly and courteously with patients, doctors, and team members at all times.

MINIMUM REQUIRED EDUCATION AND EXPERIENCE

1. High school diploma or equivalent required.
2. Minimum of one (1) year of prior ophthalmic technician or medical scribe experience required.
3. Knowledge of medical terminology and clinical documentation practices preferred.
4. Proficiency with electronic health record (EHR) systems and computer applications.
5. Certified Ophthalmic Assistant (COA), Certified Ophthalmic Technician (COT), or Ophthalmic Scribe Certified (OSC) preferred but not required.
6. Excellent verbal and written communication skills with strong attention to detail.
7. Ability to work effectively in a fast-paced, multi-site environment.

POSITION REQUIREMENTS

1. Must successfully complete a comprehensive background check as a condition of employment, including prior to any transfer or promotion within the organization.
2. Demonstrates professionalism, integrity, and cultural competence in all interactions.
3. Ability to manage multiple priorities, meet deadlines, and work independently or collaboratively as part of a team.
4. Must be willing and able to travel between assigned clinic locations as needed.
5. Maintains confidentiality of all patient, employee, and company information.

PHYSICAL REQUIREMENTS

1. Ability to sit or stand for extended periods throughout the workday.
2. Frequent use of computer, keyboard, and mouse for data entry and documentation.
3. Manual dexterity sufficient to operate clinical equipment and office devices.
4. Visual and auditory ability sufficient to observe, document, and communicate effectively.
5. Occasional lifting of materials up to 10 pounds.