Certified Medical Assistant - Clinical Assistant (General Surgery)

The Clinical Assistant Certified Medical Assistant is responsible for functioning as an assistant to the physician in the areas of direct and indirect patient care, laboratory procedures, charging, scribing, and medical records. Functions as a real time documenter of physician services performed during a patient encounter.

Job Relationships

• Reports to the Operations Manager

Principal Responsibilities

• Accompany the physician during a complete visit encounter and accurately document in real time the words, actions, physical examination findings, procedures and treatments as performed and dictated by the physician.
• Enter information into the EHR under own log in.
• Room patient, fill in initial history of present illness template to be reviewed by physician and patient, and modify the template while transcribing during clinical encounter with provider.
• Keep clear separation of duties when performing independent role with patient vs. transcribing communication (verbal and non-verbal) between provider and patient.
• Assist in organizing the nursing station and work area to facilitate good workflow.
• Organize all written medical information for physician’s/nurse’s review and place in the record in correct order.  Proof read appropriate dictation.
• Assist in answering phones and prioritize call for physician, nurse and receptionist.
• Schedule appointments effectively and efficiently according to patient needs.
• Open mail and distribute to appropriate person, file miscellaneous office information, organize all written communication.
• Order all office supplies utilizing cost containment methods.
• Order all medical supplies, stock exam rooms, and clean according to Infection Control Policies.
• Follow all Clinic policies including the Nursing Dress Code Policy. Adhere to clinic performance standards.
• Make decision regarding priority and disposition of patient complaints. Report appropriate information to supervisor.
• Interview patient to determine chief complaint and document information in medical record.
• Take vital signs and document results.
• May perform office procedures such as but not limited to sterile urine cath, suture removal, staple removal or removal of casts under the direction of a NP, PA, or physician.
• Order diagnostic tests, exams and procedures according to physician's order.
• Prepare patient for physician exam.
• Give patients instructions for home care, medications, etc. under NP, PA, or physician direction.
• Give medications orally, subcutaneously, and intramuscularly. May monitor IV therapy documents under the direction of the NP, PA, or physician.
• Administer allergy injections only under the direct supervision of the physician prescriber of the antigen.
• Perform pre-certifications/referral for insurance companies as necessary.
• Provide patient/family education and reinforce all patient teaching.
• Call in prescriptions to pharmacy, provide patient instructions and document.
• Comply with the Springfield Clinic incident reporting policy and procedures.
• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
• Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
• Perform other job duties as assigned.

Education/Experience

• High School graduate or GED required.
• Graduate of an accredited medical assisting program.
• Two (2) years’ clinical experience in a medical office environment.

Licenses/Certificates

• Must be a registered or certified Medical Assistant through one of the following: American Med Techs (AMT), American Association of Medical Assistants (AAMA), National Center for Competency Testing (NCCT), National Health Career Association (NHA), American Allied Health (AAH) at time of hire, or National Association for Health Professionals (NAHP).
  • If a different credentialing body is presented it will need reviewed and approved by the Director of Nursing.
• CPR certification per American Heart Association guidelines required within 30 days of hire.

Knowledge, Skills and Abilities

• Ability to maintain separate roles with patient, acting independently when rooming patient and transcribing interaction between provider and patient.
• Excellent communication skills.
• Excellent critical thinking skills.

Working Environment

• Works in office setting during the hours the Clinic is available to patients/families.
• Minimal lifting requirements. Occasional lifting required.
• Sitting vs. standing averages to 20-80%.

PHI/Privacy Level

• HIPAA1