Scribe

Job Summary:

This position works to improve documentation and make the process of treating patients and relatives more efficient by handling electronic health records and documenting visits. This role completes clerical tasks related to communication and recordkeeping. People in this position will accompany providers into patient rooms to manage medical documentation by summarizing their provider and patient interaction. Medical scribes prepare records for transcription and review medical documentation for errors, typos, and inconsistencies.

Essential Functions:

• Prepares and assembles medical record documentation and charts for provider(s).
• Enters the patient/relative room with the provider during patient/relative visits to capture and transcribe medical record documentation using electronic medical record applications.
• Ensures medical record compliance by self-documentation attestation.
• Updates patient/relative history, physical exam, and other pertinent health information in the patient/relative record.
• Prepares and sends all documentation to the provider for review and approval via authentication of detailed data entry and facility-specific procedures.
• Monitors the duration of basic lab results and screening procedures.
• Complies with Oyate Health Center (OHC) policies, including those related to the Health Insurance Portability Accountability Act (HIPAA), and any relevant accreditation agency(ies).
• Performs other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.

Professional Behavior:

• Work in a cooperative and professional manner with OHC and GPTLHB staff.
• Prepares and assembles medical record documentation and charts for physician(s).
• Treat Great Plains tribes and collaborators with dignity and respect.
• Utilize effective verbal and written communication skills.
• Advance personal educational development by attending training sessions and seminars as appropriate.
• Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
• Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
• Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
• Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation, and/or personalities.
• Maintain and ensure organizational privacy and confidentiality.
• Handle crisis and tolerate stress professionally.
• Be self-directed and take proactive initiative to assist others.
• Resolve issues with other departments and coworkers without direct supervision if needed.
• Exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
• Promote an alcohol, tobacco, and drug-free lifestyle.
• Embrace modes of appearance and attire that reflect a professional presence.
• Adhere to GPTLHB policies and procedures.
• Other duties as assigned by the Supervisor.

Requirements

• Participates in Core Connections training, and applies GPTLHB Core Connections concepts and practices in their work
• Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
• Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
• Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
• Familiarity and/or experience working with American Indian populations and respect for and knowledge of traditional, cultural, and spiritual practices of diverse American Indian communities, as well as an ability to work with other culturally and ethnically diverse populations.
• Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation and/or personalities.
• Maintain and ensure organizational privacy and confidentiality.
• Must be able to handle crisis and tolerate stress professionally.
• Must be self-directed and take proactive initiative to assist others.
• Possess the ability to resolve issues with other departments and coworkers without direct supervision.
• Able to exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
• Ability to maintain a flexible work schedule, including evenings, weekends and overnight or extended travel as necessary.
• Ability to effectively present information in one-on-one and small group situations to community members, consumers, and other employees of the organization.
• Proficiency with computer programs (Word, Excel, PowerPoint) and other Internet technologies.
• Valid driver’s license must be kept current, and certificates, credentials or licenses must be kept current and consistent with regulations required by applicable federal, state and/or grant regulations.
• Ability to promote an alcohol-, tobacco- and drug-free lifestyle.
• Embrace modes of appearance and attire that reflect a professional presence.
• Adhere to GPTLHB policies and procedures.

Supervisory Controls:
The supervisor provides continuing or individual assignments by generally indicating what is to be done, limitations, quality and quantity expected, deadlines, and priority of assignments. When there are new, difficult, or unusual assignments, the supervisor provides additional, specific instructions for including suggested work methods or advice on source material available.

The employee uses initiative in carrying out recurring assignments independently without specific instructions but refers deviations, problems, and unfamiliar situations not covered by instructions to the supervisor for decision or help.

The supervisor reviews finished work to ensure the methods used are technically accurate and in compliance with instructions or established procedures. Review of the work increases with more difficult assignments if the employee has not previously performed similar assignments.

Guidelines:
Guidelines are available but are not completely applicable to the work or have gaps in specificity.

The employee must use judgment in interpreting and adapting guidelines, such as agency policies, regulations, precedents, accreditation requirements, advanced clinical protocols, and work directions for application to specific cases or problems. The employee analyzes results and recommends changes.

The employee uses initiative and resourcefulness in deviating from traditional methods or researching trends and patterns to develop new methods, criteria, or proposed new policies.

Complexity:
The work consists of related steps, processes, or methods. The decision regarding what needs to be done involves various choices that require the employee to recognize the existence of and differences among a few easily recognizable situations. Actions to be taken or responses to be made differ in such things as the source of information, the kind of transactions or entries, or other differences of a factual nature.

Scope and Effect:
The work involves the execution of specific rules, regulations, or procedures and typically comprises a complete segment of an assignment or project of a broader scope. The work product or service affects the accuracy, reliability, or acceptability of further processes, services, and/or patient care.

Personal Contacts:
The personal contacts are with employees in the organization but outside the immediate department. People contacted generally are engaged in different functions, missions, and kinds of work, and may be representatives from various levels and departments within the organization, partner organizations, Tribal affiliate organizations, and employees of other healthcare organizations. Personal contact, at this level, may also be made with members of the general public, as individuals or groups, in a moderately structured setting.

Purpose of Contacts:
The purpose is to obtain, clarify, or give facts or information regardless of the nature of those facts; i.e., the facts or information may range from easily understood to highly technical.

Physical Demands:
The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items, such as papers, books, or small parts; or driving an automobile. The employee must be able to read, write, speak and hear.

Work Environment:
The work is sedentary. Typically, the employee sits comfortably to do the work. However, there may be some walking; standing; bending; carrying of light items, such as papers, books, or small parts; or driving an automobile. The employee must be able to read, write, speak, and hear.

Supervisory and Management Responsibility:
This position has no formally assigned supervisory responsibility or authority. The employee is responsible only for the performance of their own assigned work. They may be asked to train new employees in the fundamentals of the jobs or to participate in cross‑training of other employees in the department, but such assignments do not include the ongoing authority to assign and review work of other employees or to recommend or take corrective action with regard to other employees' performance.

Direct Reports:
Not Applicable.

Qualifications:
Minimum Education and Experience Requirements:
Education/Relevant Experience: high school diploma or GED and one (1) year of experience.

This position requires no post-secondary education. Qualified individuals must have relevant experience demonstrating knowledge of basic or commonly used rules, procedures, or operations that typically require completion of a training program or one (1) year of relevant experience.

Preferred Education Requirements:
Associate degree with pre-health career track.

Preferred Experience Requirements:

Knowledge of medical terminology and human anatomy. Skilled in operating various medical software and hardware, word-processing, and database software programs. Minimum of 60 WPM .

The GPTLHB is a tribal organization that follows tribal preference laws. Our policy is to give preference to qualified Indian/Tribal candidates over qualified non-native candidates in hiring decisions if all other qualifications are equal.

Employment is contingent upon the outcome of all required criminal background checks.