Job Summary:

Under the direction of the Director and Associate Director of Practice Enhancement, the Lead Scribe supervises the scribe staff at their assigned RWJBH facility. This includes managing scribe job performance (training, coaching, mentoring); creating the site monthly scribe schedule; liaison between site clinicians, corporate management, and scribes. In addition, the Lead Scribe continues to work clinical scribe shifts at the same location to provide documentation assistance and scribe services in the Emergency and Hospitalist Medicine Departments at the direction of a Physician or Advanced Practice Provider (Nurse Practitioner or Physician Assistant). The medical scribe job allows the clinician to focus on each patient, spend more time at the bedside, and work more efficiently. A medical scribe does not act independently, but documents the clinician s previously determined dictation and/or activities in the electronic medical record (EMR).

Essential Duties and Responsibilities:

• Take verbal dictations or take notes while accompanying clinicians in patient rooms
• Document clinician s dictations into the EMR, that reflect the full complexity of care provided; including patient history, physical exams, procedures, orders, diagnostics, medications and conversations with the patient, family, or consulting clinicians
• Gather and input patient information from external sources (e.g. outpatient diagnostics, nursing home records, EMS run sheets, etc.). Place phone calls to PMD offices, pharmacies, etc. as requested by the clinician
• Actively listen to all conversations pertaining to patient care between the clinician and other healthcare providers, patients, family, etc. and document relevant information into the EMR.
• Ensure documentation meets requirements for risk management, billing, etc.
• Keep clinicians informed of resulting diagnostics and troubleshoot delays in those results.
• Seek out missing or previously not dictated information from clinicians to complete the physician chart
• Alert the clinician when the physician chart is ready for their review
• Follow site downtime protocol when necessary, offer to help other scribes or clinicians with physician charts
• Assist the clinician in navigating the EMR
• Identify and anticipate clinician need and respond in an effective manner
• Perform other duties as assigned

Essential Duties and Responsibilities of Lead Scribe role:

• Supervise scribe staff at assigned facility
• Maintain knowledge of department and system policies
• Timely response to all communications
• Provide training, mentoring, and coaching to site scribes
• Seek out performance feedback and deliver feedback to scribe as needed
• Properly address scribe issues and concerns
• Draft monthly site scribe schedule
• Manage daily site schedule, including addressing open shifts/call-outs
• Assist Corporate management with recruiting and interviewing scribe candidates
• Drive to completion department initiatives for assigned site
• Attend monthly meetings with corporate management, site medical director; and other meetings as needed
• Conduct quarterly site meetings
• Develop/Maintain site manual
• Help identify areas of improvement in the scribe work flow
• Perform other duties as assigned

Competency and Skills:

• Proven proficiency as a scribe
• Excellent communication skills
• Strong knowledge of the ED/HM operations
• Superb leadership skills
• Detail-oriented resulting in accurate and thorough work
• Excellent organizational and time management skills
• Able to work in a fast-paced, stressful environment

Work Requirements:

• Ability to work any shifts, including overnights, weekends, holidays

Education/Experience Requirements:

• High School Diploma, Bachelor s degree preferred
• Minimum 6 months experience as a scribe required
• Management/Leadership experience preferred
• Training/Mentoring experience preferred

RWJBarnabas Health is the most comprehensive health care delivery system in New Jersey, with a service area covering five million people. The system includes eleven acute care hospitals Clara Maass Medical Center in Belleville, Community Medical Center in Toms River, Jersey City Medical Center in Jersey City, Trinitas Medical Center in Elizabeth, Monmouth Medical Center in Long Branch, Monmouth Medical Center Southern Campus in Lakewood, Newark Beth Israel Medical Center in Newark, RWJUH- New Brunswick, RWJUH- Somerset in Somerville, RWJUH- Hamilton, RWJUH- Rahway and Cooperman Barnabas Medical Center in Livingston; three acute care children s hospitals and a leading pediatric rehabilitation hospital (Children s Specialized Hospital), a freestanding 100-bed behavioral health center, trauma centers, a satellite emergency department, ambulatory care centers, geriatric centers, the state s largest behavioral health network, comprehensive home care and hospice programs, fitness and wellness centers, retail pharmacy services, a medical group, multi-site imaging centers and an accountable care organization.

We offer a great work environment, flexible hours, competitive rates and excellent benefits, including:

• Medical/Dental/Vision plans
• 401 (k)
• PTO
• Short- & Long-Term Disability
• Basic Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts