POSITION:
Scribe/Ophthalmic Writer
DEPARTMENT:
Patient Care
REPORTS TO:
Doctors, Administrator and Billing Manager
JOB SUMMARY:
This individual is responsible for providing accurate documentation and
summarization of the ocular examination and recommendations while
maintaining patient flow and communication regarding appointment
status. Additionally, they are responsible for maximizing optical and
contact lens sales with the use of the Vision Lifestyle Questionnaire and
Insurance Authorization, maximize patient continuity of care and
maximize/afford/follow patient’s insurance benefits and requirements.
EDUCATION AND EXPERIENCE:
1. High school diploma.
2. Fluency in English, bilingual preferred.
3. Basic understanding of algebraic principles.
4. Four years experience in a medical office.
5. Excellent spelling ability.
6. Medical Terminology certificate.
7. Certification in Billing and Coding – specifically Ophthalmology.
8. Eye Code and Evaluation and Management Coding Certification.
ESSENTIAL SKILLS AND ABILITIES:
1. Experience maintaining patient confidentiality.
2. Strong professional interpersonal skills.
3. Demonstrated respect for staff and patients.
4. Excellent verbal and written communication.
5. Team-orientation.
6. Management of multiple projects simultaneously.
7. Strong organization with attention to detail.
8. Legible handwriting.
9. Computer literacy.
10. Leadership qualities.
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RESPONSIBILITIES:
1. Correctly summarizes and documents what the physician says during an examination,
including but not limited to: proper charting of the examination, documenting additions to the
chief complaint, assessment and recommendations for treatment (including justification of
decisions reached when appropriate).
2. Observes the patient and the physician and assists when appropriate during the exam or
procedure, including but not limited to: holding the patient’s head in the slit lamp, providing
additional medications and/or instruments, following directions in a medical emergency.
3. Maintains an awareness of the patient’s verbal and non-verbal communication when the
physician is providing instructions as it may necessitate the writer repeating information,
providing written instructions, and/or patient education materials for the patient to review at
home.
4. Ensures patient understands all instructions.
5. Accurately documents chart errors according to the following format:
a. One line is to be drawn through the mistake.
b. The initials of the person making the error are to be written.
c. The corrected information can then be documented.
6. Maintains patient flow, by ensuring a minimum of two patient rooms are always occupied.
7.
Remains as close to the physician as possible and limits time away from the physician and
the patient.
8. When applicable, prepares accurate eye glass or contact lens prescriptions and/or medication
prescriptions for the eye physician’s signature prior to the completion of the examination.
9. Alerts eye physician to patient-related forms that need completion.
10. When appropriate, completes the superbill and/or the check-out form, providing direction to
the patient prior to following the physician.
11. Guides patient to front desk after completion of exam and ensures proper follow-up
appointments are made.
12. Learns the personality and preferences of each physician, recognizing differences and
abiding by them when working with that particular physician.
13. Becomes fluent in the exact requirements of each examination.
14. Accommodates the needs of the patient for the exam:
a. Monitors examination room and any physical limitations the patient may have.
b. Makes sure the patient chair is down before the patient prepares to leave, the equipment
is off, the slit lamp is out of the way, etc.
c. Provides patient with cane, handbag, coat, etc. to expedite patient flow.
Scribe/Ophthalmic Writer
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d. Evaluates the condition of the examination room to ensure adequate supplies are in stock.
e. Notifies physician of changes to the daily schedule, especially emergencies.
f. Performs other tasks as required.
g. Miscellaneous tasks: allergy stickers completed, PQRI, E-Rx and written prescriptions
including instructions, prepare contact lens orders, initiate surgery scheduling
instructions, discuss back up pairs of glasses for cls users and discuss overuse with
handhout, maximize eye codes, check compliance with eye codes and evaluation and
management codes, maximize encounters, verify patient follow up with vision vs
medical, capture all applicable services for the day ie, second eye interpretations
including documentation, medical necessity met and documented for procedures/surgery
ie, 20/40 cataract extraction, documentation about handouts or samples given including
instructions, fill doctor exam lanes with dilated patients, transport patients either optical
or check out and meet requirements for HPI according to Medicare bylaws, QMB and
QMB only.
15. Update and review abbreviation sheet with physicians and technicians to make sure the
same abbreviations are being used throughout the patient care dept.
PHYSICAL ABILIITES:
1. Must be able to walk and stand for eight hours.
2. Must be able to type or write legibly in a dimly-lit setting.
3. Must be able to hear softly spoken words.
ADDITIONAL TRAINING:
BSM Introduction to scribing.
Compulink Computer Classes: All as applies to role.
Abbreviation Sheet specific to Munster Eye Care Associates, P.C.
Code and Bill charts with billing personnel.
Corcoran Classes on Billing and Coding Eye Codes and Evaluation and Management Codes.
Saved, lb, 8/27/2012, admin drive, corporate data folder, human resource folder, job descriptions folder, word, scribe/ophthalmic writer folder