Position Classification Description

Position Class Code / Title: A1014 / Medical Scribe
Recruitment Tier: Tier 1
FLSA: Non-Exempt
Grade: 09

This is a description of a Staff Position Classification. It is not an announcement of a position opening. To view descriptions of current openings, please go to UNMJobs and Search Postings to view positions that are currently accepting applications.

The following statements are intended to describe, in broad terms, the general functions and responsibility levels characteristic of positions assigned to this classification. They should not be viewed as an exhaustive list of the specific duties and prerequisites applicable to individual positions that have been so classified.

Summary

Analyzes patient medical records to assure that documentation by providers conforms to legal and procedural requirements. Assists physicians and medical provides in accurately documenting patient encounters. This includes but, not limited to, documenting key portions of the medical note include the History of Present Illness, Review of Systems, Past Medical History, and the Physical exam 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. Assigns accurate evaluation and management codes to ensure proper coding of patient charts.
  3. Interacts with department heads and other administrative staff regarding implementation of new codes and revision of charge documents.
  4. Researches inquiries from providers regarding patient charts.
  5. Ensures strict confidentiality of financial and medical records.
  6. Follows established departmental policies, procedures, and objectives, ensuring continuous quality improvement and adherence to safety and environmental standards.
  7. Remains up-to-date on coding information and regulatory changes through attendance at conferences, workshops, and in-house training sessions.
  8. Enter patient information to include diagnosis, studies, orders. interpretations as dictated by the provider and into the appropriate health record system.
  9. Performs miscellaneous job-related duties as assigned.

Minimum Job Requirements

  • High school degree or GED; at least 6 months of experience directly related to the duties and responsibilities specified
  • 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/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

  • No or very limited physical effort required.
  • No or very limited exposure to physical risk.
  • 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.

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

Revised Date: