Traveling Ophthalmic Scribe

JOB TITILE: TRAVELING OPHTHALMIC 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.