Summary

Provides day-to-day coordination and leadership to the scribe program as assigned. Analyzes patient medical records to ensure that documentation by providers conforms to legal and procedural requirements. Assists physicians and medical providers in accurately documenting patient encounters. This includes but is not limited to documenting key portions of the medical note as directed by the provider. Interacts with physicians and other providers to ensure proper coding of patient charts, maximized efficiency, and optimization of patient throughput.

Duties and Responsibilities

1. Accompanies with medical providers during patient encounters to transcribe the history and physical examination as the patient is evaluated; audits physician charts and provide appropriate feedback.
2. Oversees the work of employees in supporting roles, including assigning workload and monitoring employee performance.
3. Designs and conducts orientation and training in the area of specialty, including the delivery of current department and division policies and procedures.
4. Assign accurate evaluation and management codes to ensure proper coding of patient charts through conducting medical chart reviews.
5. Interacts with department heads and other administrative staff regarding implementation of new codes and revision of charge documents.
6. Researches escalated, highly complex, and/or sensitive inquiries from providers regarding patient charts.
7. Ensures strict confidentiality of patient medical and financial records.
8. Follows established departmental policies, procedures, and objectives, ensuring continuous quality improvement and adherence to safety and environmental standards.
9. Remains up-to-date on EMR changes, coding practices and requirements, training, policies, compliance, and regulatory changes through attendance at conferences, workshops, and/or in-house training sessions.
10. Enter patient information to include diagnosis, studies, orders. interpretations as dictated by the provider and into the appropriate health record system.
11. Performs miscellaneous job-related duties as assigned.

Minimum Job Requirements

• High School diploma or GED - min of 1-year experience directly related experience.
• Completed degree(s) from an accredited institution that is above the minimum education requirement may be substituted for experience on a year-for-year basis.

Knowledge, Skills and Abilities Required

• Knowledge of legal and policy constraints pertaining to patient billing.
• Ability to communicate effectively, both orally and in writing.
• Ability to gather data, compile information, and prepare reports.
• Knowledge of auditing concepts and principles.
• Knowledge of medical terminology.
• Ability to analyze complex medical records.
• Ability to use independent judgement and to manage and impart confidential information.
• Ability to maintain quality, safety, and safety, and/or infection control standards
• Ability to analyze and solve problems.
• Knowledge of current and developing issues and trends in medical coding procedures requirements.
• Knowledge of patient care charts and patient histories.
• Ability to clearly communicate medical information to professional practitioners and/or the general public.
• Ability to relay technical information to both technical and non-technical personnel.

Conditions of Employment

• Must successfully complete all required training within 6 months of hire.
• Employees who provide services or work in patient care or clinical areas are required to be in compliance with the University's influenza vaccination requirement.

Working Conditions and Physical Effort

• Moderate physical activity; requires handling of average-weight objects and standing or walking for extended periods of time.
• Work is performed in an interior medical/clinical environment.
• Work may involve some exposure to operating circumstances that require following standard or prescribed safety precautions.
• Need for holiday/weekend/night availability, available to work a minimum of 2 shifts/week, must be able to stand for the majority of shift.

The University of New Mexico provides all training required by OSHA to ensure employee safety.

Revised Date: 02/02/2024