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Onsite Medical Documentation Assistant in Kingsport, TN at TeamHealth

Date Posted: 5/21/2020

Job Snapshot

Job Description

The Medical Documentation Assistant provides a variety of administrative, patient care services and documentation assistance under the supervision of a clinician. Support from the Medical Assistant optimizes workflow for the clinician allowing them to achieve higher productivity. The exact scope of the Medical Assistant’s responsibilities may vary depending on the type of practice, facility and needs of the clinician they are working with.

The Medical DocumentationAssistant carries out his/her duties by adhering to the highest standards of ethical and moral conduct, acts in the best interest of TeamHealth and fully supports TeamHealth’s focus on supporting its clinicians. The Medical Documentation Assistant will comply with HIPAA and company policy by managing sensitive and confidential matters such as patient information and protecting the security of information, data and files.

A Medical Documentation Assistant may not evaluate a patient, make a medical assessment or give medical advice. The clinician must determine the skill level and capabilities of each Medical Assistant and take into account the liability risk and quality control when assigning responsibilities.

The position reports to the Clinical Practice Manager with day to day supervision provided by the clinician

 

Job Requirements

Administrative

Performs administrative tasks that do not require medical licensure:

  • Manages census data in the post-acute facilities, audits for accuracy
  • Assists with scheduling and tracking of regulatory visits
  • Assists with obtaining missing face sheets, upon request
  • Obtains and organizes forms for clinician review & signature (certifications, consults, incident reports, pharmacy recommendations including GDRs)
  • Maintains census in gEHRiMed
  • Attaches scanned documents and pictures to gEHRiMed
  • Updates patient information in gEHRiMed
  • Adds alerts to gEHRiMed such as hospice or any category that may be applicable in the future
  • Enters new patients in gEHRiMed
  • Performs special assignments and other related tasks as directed by clinician or CPM

 

Patient Care Services

  • Accompanies clinicians at facilities for rounding
  • Prepares rounding list and gathers necessary information for clinician:
  • Patients to be seen
  • Lab/test results
  • Vital Signs, Weights, Accuchecks
  • Medication Administration Record (facility EHR or paper)
  • Gather patient for clinician visit as directed by clinician

Documentation Assistance/Scribe Duties

  • May assist clinician with documentation either in person or remotely
  • Accompany clinician during the patient visit to document, verbatim, information elicited during the visit in to the medical record, at the sole direction of the clinician
  • Records historical patient information by copying, verbatim, from outside medical records into gEHRiMed, or verbatim from the clinician, including, but not limited to:
  • Demographic information and updates
  • Allergies
  • Immunization Record
  • Past Medical History
  • Past Surgical history
  • Social History
  • Family History
  • Medication Record
  • Records in gEHRiMed
  • Verbatim from the Clinician:
  • Chief Complaint
  • History of Present Illness
  • Review of Systems
  • Physical Exam
  • Plan
  • Discussions with patient and family
  • Time elements, when required
  • Attestations
  • Every note requires two attestations: one by the clinician and one by the Medical Assistant

Medical Assistants May Not:

  • Record Diagnosis/ICD-10 codes
  • Record MIPS Quality Measures
  • Record CPT codes
  • Enter orders
  • Sign orders
  • Administer or Prescribe Medications
  • Independently speak with patients to obtain information to be entered in the progress note
  • Communicate any medically relevant information to the patients or families
  • Render physical care to patients

 

QUALIFICATIONS / EXPERIENCE:

  • 2+ years’ experience working as a Medical Assistant in a clinical setting
  • Able to perform, satisfactorily, any of the requirements listed above that are applicable to the setting and clinician
  • Medical Assistant certification preferred
  • Ability to review documents for accuracy and reasonability
  • Intermediate computer skills required
  • Ability to type efficiently and accurately
  • High School Diploma required
  • Ability to appropriately handle confidential information
  • Excellent, professional verbal and written communication skills