Ophthalmic Scribe, Clinical Documentation & ICD-10 Coding
Overview
You will own real-time clinical documentation for an ophthalmic practice, transcribing physician dictation during patient exams with CPC Card precision. You will manage coding integrity with ICD-10 and CPT designations, ensuring accurate billing and compliant records. As part of a clinical team, you will collaborate with ophthalmologists and technicians to streamline patient flow from check-in to discharge. This role blends administrative rigor with hands-on patient support, offering direct exposure to ophthalmic procedures and diagnostic workflows. You will also assist with insurance verifications and schedule adjustments, making you a critical link between clinical and front-office operations.
What You'll Do8
- 1Transcribe physician dictation in real time during ophthalmic exams, capturing patient histories, diagnostic evaluations, and treatment plans with ICD-10 accuracy.
- 2Assign precise CPT codes for procedures and visits, maintaining billing integrity and reducing claim denials.
- 3Process chart amendments per protocol, ensuring compliance with HIPAA and clinic standards.
- 4Assist with insurance verifications and schedule adjustments, coordinating with front-desk staff to finalize follow-up care before patient departure.
- 5Anticipate provider needs during exams, preparing rooms and equipment for slit lamp, tonometry, and fundoscopy.
- 6Perform basic ophthalmic technician duties, including visual acuity testing and pupil dilation under supervision.
- 7Explain discharge instructions to patients, confirming understanding of medication regimens and follow-up appointments.
- 8Document patient interactions in EHR systems, maintaining real-time accuracy to support clinical decision-making.
Requirements8
- 11+ year experience as a medical scribe or in a clinical documentation role, ideally in ophthalmology.
- 2Proficiency with ICD-10 and CPT coding, with certification such as CPC Card preferred.
- 3Strong typing speed (min 60 WPM) and ability to document in real time with high accuracy.
- 4Familiarity with EHR platforms like Epic, Cerner, or Athena.
- 5Knowledge of ophthalmic terminology and procedures, including refraction, visual field testing, and OCT.
- 6Ability to multitask in a fast clinical environment, prioritizing tasks without losing detail.
- 7High school diploma or equivalent; Associate's or Bachelor's degree in pre-med or health sciences preferred.
- 8Comfort with direct patient interaction and basic clinical support duties.
Salary Insight
$42 - $50k per year
Location
Required Skills
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