Hybrid Medical Assistant / Medical Scribe

Description

Job Title: Hybrid Medical Assistant / Medical Scribe

Classification: Full Time / Non-Exempt

Salary: $17 -20 per hour

Reports to: Clinic Director

Position Summary

The Hybrid Medical Assistant / Medical Scribe supports the delivery of high-quality, patient-centered care by combining traditional Medical Assistant responsibilities with real-time clinical documentation support for providers. This position assists with patient rooming, vital signs, clinical intake, screenings, medication and history reconciliation, procedure preparation, lab coordination, and other clinical support duties while also accurately documenting provider-patient encounters in the electronic health record.

The role is designed to improve clinic flow, strengthen documentation accuracy, support provider efficiency, and enhance the patient experience. The employee must be able to move between hands-on clinical support and documentation support based on provider needs, clinic volume, staffing levels, and patient care priorities.

Essential Duties and Responsibilities

Medical Assistant Responsibilities

The Hybrid Medical Assistant / Medical Scribe performs standard Medical Assistant duties within their scope of training, certification, licensure, and organizational policy, including but not limited to:

• Rooms patients and prepares them for provider visits.
• Obtains and documents vital signs, chief complaint, allergies, medication list, preferred pharmacy, medical history, surgical history, family history, social history, and other intake information as appropriate.
• Performs medication reconciliation and updates the electronic health record accurately.
• Reviews and updates preventive care, health maintenance, and screening information.
• Assists providers with examinations, procedures, treatments, and minor office-based interventions.
• Prepares exam rooms, equipment, and supplies before and after patient visits.
• Administers medications, vaccines, injections, or treatments only as permitted by training, competency, standing orders, provider direction, and organizational policy.
• Collects specimens, performs point-of-care testing, and processes lab orders according to clinic protocol.
• Ensures labs, diagnostic testing, referrals, and follow-up instructions are communicated and documented appropriately.
• Provides patient education as directed by the provider, using approved materials and standard workflows.
• Monitors patient flow and communicates delays, room availability, and patient needs to the provider and care team.
• Maintains infection control standards, universal precautions, and clean clinical workspaces.
• Documents all clinical activities accurately and timely in the electronic health record.
• Participates in inventory management, including clinical supplies, vaccines, medications, and equipment as assigned.
• Supports quality initiatives, including UDS, preventive screenings, chronic disease measures, immunizations, and other care gap workflows.

Medical Scribe Responsibilities

When functioning as a Medical Scribe, the employee documents the patient encounter in real time or near-real time under the direction of the provider. Duties include:

• Accurately documents the provider-patient encounter in the electronic health record.
• Records the history of present illness, review of systems, physical examination findings, assessment, plan, patient instructions, and follow-up recommendations as directed by the provider.
• Documents diagnoses, orders, referrals, medications, procedures, and disposition information based on provider instruction.
• Assists with pending orders, referrals, labs, imaging, prescriptions, and follow-up tasks for provider review and signature.
• Captures relevant clinical context while avoiding independent medical interpretation or decision-making.
• Ensures documentation reflects only what occurred during the visit and what was communicated by the provider or patient.
• Routes incomplete documentation, provider questions, or missing information to the provider promptly.
• Supports timely note completion by preparing accurate draft documentation for provider review.
• Maintains awareness of documentation standards, including medical necessity, compliance, privacy, and billing-related documentation expectations.
• Does not independently diagnose, determine treatment plans, prescribe, interpret test results, or make clinical decisions.

Hybrid Workflow Expectations

This position requires flexibility and the ability to shift between clinical and documentation responsibilities throughout the day. Depending on clinic need, the employee may:

• Function primarily as a Medical Assistant during high-volume clinic flow.
• Function primarily as a Medical Scribe for assigned providers.
• Support both roles during the same visit, while maintaining appropriate patient care and documentation boundaries.
• Assist with pre-visit planning, rooming, documentation, patient discharge, and follow-up task routing.
• Communicate clearly with providers regarding incomplete documentation, patient concerns, or workflow barriers.
• Prioritize patient safety and clinic flow over non-urgent administrative tasks.

The position is not intended to replace provider documentation review or provider clinical judgment. The provider remains responsible for reviewing, correcting, approving, and signing all clinical documentation.

Compliance and Confidentiality

The Hybrid Medical Assistant / Medical Scribe must comply with all applicable organizational policies, HIPAA requirements, privacy standards, infection control expectations, and regulatory requirements. This includes:

• Maintaining patient confidentiality at all times.
• Accessing only the minimum necessary patient information needed to perform job duties.
• Ensuring all documentation is accurate, timely, and completed under appropriate provider direction.
• Following organizational policies related to consent, AI documentation tools, student/trainee presence, patient privacy, and sensitive health information.
• Reporting documentation errors, privacy concerns, safety issues, or workflow concerns to the appropriate supervisor.
• Maintaining professional boundaries and a respectful, trauma-informed approach to patient interactions.

Requirements

Required Qualifications

• High school diploma or equivalent required.
• Completion of a Medical Assistant training program preferred.
• Medical Assistant certification preferred, or willingness to obtain if required by organizational policy.
• Prior experience in a medical office, clinic, FQHC, community health center, or outpatient setting preferred.
• Experience with electronic health records required or strongly preferred.
• Strong typing, computer, and documentation skills.
• Ability to accurately capture clinical information while maintaining attention to detail.
• Knowledge of medical terminology, common outpatient workflows, and basic clinical procedures.
• Ability to maintain confidentiality and comply with HIPAA requirements.
• Strong communication, organization, and multitasking skills.
• Bilingual English/Spanish preferred.

Preferred Qualifications

• Experience using eClinicalWorks or similar electronic health record system.
• Prior scribe experience in primary care, behavioral health, infectious disease, HIV care, or community health.
• Experience supporting quality measures, referrals, lab workflows, and care gap closure.
• Familiarity with FQHC operations, sliding fee programs, Ryan White services, UDS measures, and integrated care models.
• Current CPR/BLS certification.

Knowledge, Skills, and Abilities

The successful candidate must demonstrate the ability to:

• Work efficiently in a fast-paced clinical environment.
• Communicate professionally with patients, providers, and team members.
• Accurately document clinical encounters without inserting personal assumptions or unsupported information.
• Understand the difference between documenting provider-directed information and making clinical decisions.
• Maintain a calm and professional demeanor during busy clinic sessions.
• Prioritize tasks based on patient care needs and provider workflow.
• Use good judgment when handling sensitive patient information.
• Support a welcoming, respectful, and patient-centered care environment.
• Accept feedback and make corrections to documentation or workflow practices.
• Maintain flexibility when assigned duties change due to clinic needs.

Scope of Practice Limitations

The Hybrid Medical Assistant / Medical Scribe may not:

• Diagnose medical conditions.
• Interpret lab, imaging, or diagnostic results independently.
• Create treatment plans.
• Prescribe, refill, discontinue, or modify medications without provider direction.
• Provide independent medical advice.
• Document services that were not performed.
• Enter provider orders unless permitted by organizational policy and under appropriate provider direction.
• Sign clinical documentation on behalf of a provider.
• Make independent decisions about patient disposition, referrals, or follow-up intervals.

Physical Requirements

This position may require:

• Standing and walking for extended periods.
• Sitting and typing for extended periods.
• Lifting or moving supplies or equipment up to organizationally approved limits.
• Assisting with patient positioning or room preparation.
• Use of computers, phones, medical equipment, and clinical supplies.
• Exposure to blood, bodily fluids, infectious materials, and cleaning agents.
• Compliance with infection prevention, PPE, and workplace safety requirements.

Working Conditions

This position works primarily in an outpatient clinical setting. The employee may work in exam rooms, provider work areas, nursing stations, front clinical areas, and administrative spaces. The role requires frequent interaction with patients, providers, clinical staff, and administrative staff.

Performance Expectations

Performance will be evaluated based on:

• Accuracy, completeness, and timeliness of documentation.
• Provider satisfaction with documentation and workflow support.
• Patient care support and professionalism.
• Compliance with clinical protocols and organizational policies.
• Ability to maintain patient flow and support clinic efficiency.
• Quality of communication with patients and team members.
• Responsiveness to feedback and correction.
• Reliability, punctuality, and teamwork.
• Contribution to quality, safety, and patient satisfaction goals.