Ophthalmic - Scribe

The Ophthalmic Scribe supports providers and the patient care team by accurately documenting clinical encounters, maintaining efficient clinic workflows, and ensuring comprehensive patient records. This role requires collaboration with both front office and back-office staff, attention to detail in medical documentation, knowledge of ophthalmic terminology and procedures, and a commitment to continuous learning and professional growth. The scribe plays critical role in enhancing provider efficiency, optimizing patient care, and contributing to the overall effectiveness of the clinic. 

ESSENTIAL FUNCTIONS/RESPONSIBILITIES:

• Eager to learn, adapt to evolving clinical workflows, and embrace new technologies. 
• Committed to continuous professional growth, skill development, and knowledge expansion. 
• Strong communication skills with patients, providers, and team members. 
• Works collaboratively within the patient care team, adapting to individual MD/OD preferences while maintaining professional and respectful interactions. 
• Quickly adapts to new concepts, procedures, and clinic operations. 
• High attention to detail and accuracy in documentation, coding, and EMR usage. 
• The annual completion of assigned Learning Management System (LMS) courses is mandatory. Any individual who has not completed their assigned training prior to November 30th of each year may be subject to disciplinary action, up to and including termination of employment.
• Other duties as assigned.

Patient Care & Workflow

• Maintains efficient clinic flow to optimize provider schedules and enhance patient care.
• Supports team members during backlogs to ensure smooth operations.
• Accompanies providers during patient visits, documenting encounters accurately in a structured, detailed format.
• Completes exam documentation, including impressions, treatment or surgical plans, coding, and return-to-clinic notes prior to patient discharge.
• Assists providers and staff in understanding chart notes to determine appropriate exams, testing, or procedures.

Clinical Documentation

• Documents patient history, examinations, assessments, diagnostic results, procedures, and treatment plans in compliance with CPT and ICD-10 coding standards.
• Ensures medical necessity for treatments and procedures is clearly documented.
• Efficiently uses EMR systems, maintaining and updating templates, macros, as required.
• Prepares after-visit summaries, postoperative care instructions, and patient education materials.
• Uploads and organizes postoperative notes, diagrams, and related documentation in patient records.
• Monitors pending labs, imaging, and pathology results to support timely provider decision-making.

Specialized Knowledge & Skills

• Strong knowledge of ophthalmic anatomy, terminology, and ocular medications.
• Familiarity with common ophthalmic procedures, including diagnostic testing (refraction, lensometry imaging), minor in-office procedures, and post-operative care.
• Ability to complete patient exams, impressions, treatment or surgical plans, coding, and follow-up documentation.
• Knowledge of ocular diseases and conditions across subspecialties (e.g., retina, cornea, glaucoma, neuro-ophthalmology, anterior segment).
• High level of knowledge regarding Anti Vegf, biosimilar drugs and diagnosis eligibility (as needed for retina scribes).
• High level of knowledge regarding injectable or topical treatments and diagnosis and eligibility (as needed for subspecialities (e.g., retina, cornea, glaucoma, anterior segment).
• Understanding of genetic testing, research studies, and relevant clinical protocols.
• Proficiency in contact lens workflows, formulary/non-formulary evaluations, and patient education.

Administrative Support

• Orders and tracks laboratory, imaging, and pathology tests per provider guidance.
• Supports prior authorization processes for medications and procedures.
• Accurately completes FMLA and other medical documentation in compliance with requirements.
• Assists staff and providers by interpreting chart notes, answering clinical questions, and ensuring patient care needs are met efficiently.
• Serves as preceptor for in-clinic trainees

KEY PERFORMANCE STANDARDS:

• Job Competency - with minimal guidance, performs the essential functions of the job. 
• Attendance/Tardiness – occasionally misses work, but no significant impact on job performance.
• Integrity - walks the walk, strives to do the right thing, accountable, honest and truthful, reliable, transparent, ethical, treats other fairly.
• Customer/Patient Focus – places the patient first, active listener, attentive, compassionate, responsive. 
• Adaptability- flexible in role and thinking, open minded, willing to change, agile, pro-active, resilient, responsive to new challenges.
• Community – works collaboratively helping the next team member to do their job well, let’s go and moves on, promotes a positive work culture, treats others with respect, communicates effectively, follows through, available to others.
• Excellence – doing our best every moment of every day, professional, can-do attitude, strives to improve, follows through, manages time and resources well, work is timely and accurate, attention to detail.

SKILLS/QUALIFICATIONS:

• High school diploma or equivalent required.

• Certified Ophthalmic Assistant (COA) required or Certified Ophthalmic Technician (COT) required 
• OSC Certification required.
• Sign off by MD/OD as meeting scribe requirements. 
• Strong verbal, written, grammar, and interpersonal communication skills.
• Proficient typing skills i.e., touch typing or 40-50 WPM preferred.
• Proficient in EMR systems and medical documentation.
• Ability to learn and operate various ophthalmic and laboratory testing equipment.

PHYSICAL REQUIREMENTS:

• Ability to lift, push, and pull patients and equipment using proper body mechanics.

• Capable of standing, walking, and using fine motor skills for extended periods.
• May work under stressful conditions with schedule flexibility for emergencies.
• Requires the ability to see, speak, listen, and develop written materials.

Req. #2936