Ophthalmic Clinic Scribe

About the Role

Retina Consultants of Texas (RCTX) is seeking an Ophthalmic Scribe to join our innovative team with the mission of Fighting Blindness For The World To See. This position will be responsible for providing accurate documentation, summarization of the ocular examination and recommendations, ICD10 coding and CPT in patient charts, while maintaining patient flow and communication regarding appointment status at our Sugar Land Clinic.

Candidates must be able to travel to various clinics to meet the needs of the patients and providers, and support Clinic hours of Monday through Friday between 6:30 am - 6:30 pm. Schedules are provided weekly and are based on the provider's clinic, patient, and surgery schedules. Clinic staff are provided with the opportunity for weekend hours if available.

Key Responsibilities

• Correctly summarizes and documents what the physician verbalizes 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 and closing patient charts in a timely manner.
• Accurate ICD10 and CPT coding in patient charts.
• Observes the patient and the physician and assists when appropriate during the exam, including but not limited to: providing assistance to the patient as needed, providing additional medications and/or instruments, following directions in a medical emergency.
• Maintains an awareness of the patient’s verbal and non-verbal communication when the physician is providing instructions, as it may be necessary for the scribe to repeat information, provide written instructions, and/or hand out patient education materials for the patient to review at home.
• Ensures patient understands all instructions.
• Accurately documents amendments to patient charts according to practice protocols.
• Maintains the patient flow of the clinic to include confirmation of insurance authorization prior to treatment.
• Provides support to the clinic by helping execute Ophthalmic Technician duties as needed.
• Alerts physician to patient-related forms that need completion.
• Guides patients to the front desk after completion of the exam and ensures proper follow-up appointments are communicated to the front desk to be made before the patient leaves.
• Evaluates the condition of the examination room to ensure adequate supplies are in stock and the patient can safely enter and exit the room.
• Notifies physician of changes to the daily schedule, especially emergencies.
• Facilitates communication between the physician and other staff members as helpful to minimize clinic flow disruptions.
• Performs other tasks as assigned.

Requirements & Tech Stack

• ICD10 coding
• CPT coding
• HIPAA requirements
• English fluency (bilingual preferred)
• Medical terminology and/or ophthalmic terminology
• Computer literacy
• Ability to spell accurately while charting
• Basic math skills
• Ability to educate patients regarding instillation of eye drops and other instructions related to physician’s treatment plan.

Qualifications

• High school diploma required; bachelor’s degree preferred.
• At least 6 months experience in a medical office, preferably an ophthalmology office.
• Scribe certification (certified ophthalmic assistant), preferred.

Skills/Competencies

• Strong, professional interpersonal skills.
• Excellent verbal and written communication.
• Team-orientation.
• Ability to multi-task.
• Strong organization with attention to detail.
• Ability to walk and stand for entire work shift.
• Ability to move frequently from standing and sitting depending on exam room configuration during clinic sessions.
• Ability to type or write legibly in a dimly-lit setting.
• Ability to hear softly spoken words.
• Lifting required up to 30 pounds.
• Knows required components of examination for appropriate CPT coding to ensure all elements are accurately completed.
• Understands Medicare and other common insurance requirements for quality reporting in order to help practice comply with payer requirements.