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EMPLOYEE RISK FACTOR

I Performs tasks that involve exposure or potential exposure to blood, body fluids or body tissue, or other potentially contaminated materials.

SUMMARY:

We are seeking a compassionate and knowledgeable Licensed Vocational Nurse (LVN) to join our dedicated team at a sexual health & wellness, prevention and treatment clinic as a Scribe. This role involves assisting healthcare providers in delivering high-quality care. The LVN Scribe is responsible for supporting the team of clinicians by documenting patient encounters, managing clinical data, and assisting with other clinical tasks to ensure the smooth clinic operation and optimal patient care. This role combines both nursing and administrative duties. The LVN will work closely with the healthcare team to ensure seamless care for individuals living with HIV, maintaining high standards of confidentiality, compassion, and professionalism.

SUPERVISION RECEIVED/EXERCISED

Works under the general supervision of the Chief Medical Officer. Works under the general direction of the Director of Clinical Operations. Works under the direct supervision of the clinician for whom the scribing is being done.

ESSENTIAL DUTIES & RESPONSIBILTIES

Patient Documentation Support:

Accurately and efficiently document patient histories, physical exams, progress notes, test results, and other pertinent clinical information in electronic health records (EHR) during patient visits. Assist healthcare providers in documenting assessments, treatment plans, prescriptions, and other medical orders. Real-time charting alongside physicians and other medical staff during patient examinations and procedures, transcribing the encounter in real time. Medical record management to ensure that all medical documentation is complete, accurate, and properly formatted following medical documentation rules, with attention to detail for medical coding and billing purposes. Coordination in retrieving patient records, lab results, imaging reports, and other necessary documents for the physician's review and patient care. Patient interaction to gather essential information such as medical history or current symptoms or provide instructions or advice as directed by the healthcare provider. Ensure all documentation follows clinic protocols and complies with medical records standards and HIPAA, regulations, etc. Support clinic efficiency by streamline clinic workflow and managing tasks such as organizing patient files, preparing documents for clinicians, and ensuring timely chart completion.

Clinical Assessment:

Utilize nursing knowledge to evaluate the severity of symptoms and advise on the appropriate next steps (e.g., follow-up appointment, referral to medical provider, emergency care). Track and manage patient calls, ensuring timely responses and proper follow-up within 24-75 hours. Assist with basic patient care duties such as taking vital signs, preparing exam rooms, and conducting routine patient assessments.

Collaboration & Coordination:

Collaborate with the clinic's healthcare team, including physicians, physician's assistants, and other medical staff, to ensure comprehensive care for patient populations served. Assist with coordinating referrals or appointments for patients requiring in-person visits, specialty consultations, or diagnostic tests or for case management services. Assist in monitoring and tracking patient treatment plans, including HIV medication regimens, laboratory results, and follow-up care.

Patient Education:

Provide patients with information on HIV prevention, treatment adherence, and other relevant health concerns. Answer questions about HIV medications, side effects, and support resources available to patients. Promote health literacy, ensuring patients understand instructions and feel empowered in their care. Identify patient service requirements by establishing personal rapport with potential and actual patients and other persons in a position to understand service requirements. Participate in health promotion and education/awareness campaigns and community events. Provide guidance and education on specialty pharmacies/ medications.

Quality Assurance & Compliance:

Adhere to clinic protocols, policies, and regulatory standards (e.g., HIPAA, OSHA, etc.). Participate in training and continuing education to stay current with best practices in HIV care and patient triaging. Ensures about proper operational procedures of medical and administrative equipment by verifying availability, completing preventive maintenance requirements, troubleshooting malfunctions, repairs, maintaining equipment inventories, and evaluating and replacement of new equipment and techniques. Maintains professional and technical knowledge through CE - attending educational workshops, reviewing professional publications, or participating in professional societies. Stay updated with HIV-related treatments, care guidelines, and medical terminology. Perform other clinical duties and administrative tasks as assigned by Clinical Operations Director or medical provider. Must comply with program training requirements according to VAC policies, program and funding requirements. Must attend department and organizational meetings and attend required trainings. Must follow all agency rules and regulations including but not limited to Employee Handbook and safety protocols and programmatic. Must abide by Confidentiality and HIPAA regulations to safeguard protected health and sensitive information. Assists LVN Phone Triage, Floor nurse or Medical Assistant duties as necessary and according to VAC policies. Must attend all department, organizational meetings and attend all required trainings. Other duties as required and assigned.

QUALIFICATIONS - EDUCATION & EXPERIENCE

High School Graduate or equivalent. Graduate from an accredited Vocational Nursing Program and have received a Diploma, associate's degree, and/or Certificate. Candidates must have taken and passed The National Council Licensure Examination (NCLEX). Must hold an active license issue by the Texas Board of Nursing. Candidates must also have no restrictions on their license. At least 1 year of experience in a clinical setting, preferably in infectious disease or HIV care. Strong understanding of HIV treatment, antiretroviral therapy (ART), and associated conditions. Experience working in an HIV clinic - highly desired. Experience with electronic health records (EHR) systems is a plus. Experience of working for non-profit organizations is preferred.

QUALIFICATIONS - KNOWLEDGE, SKILLS & ABILITIES

Ability to speak fluent English; ability to handwrite legibly; ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to communicate fluently in Spanish is required. Strong knowledge of HIV care, including treatment regimens, lab results, and monitoring parameters. Detail-oriented with a high level of accuracy in documentation and data entry. Excellent communication skills, both verbal and written and strong interpersonal and communication skills. Compassionate and empathetic with ability to relate to target population from all walks of life. Ability to communicate effectively and with tact highly sensitive information. Ability to participate effectively as a team member and contribute to a positive work environment. Proficient with EHR systems and basic medical office technology. Ability to handle sensitive topics with empathy and cultural competence. Ability to respect individuality and be culturally sensitive: Understand the struggles and experiences. (e.g. the unhoused, substance-using individuals). Working knowledge of Microsoft Office Suite and Zoom Health. Ability to work under pressure in a fast-paced environment and establish and maintain effective, courteous working relationships with patients, staff members, insurance entities and others and participate effectively as a team player. Presents self in a professional manner, dress and actions. Must be able to work under conditions of constant interruption and be able to stay on task and follow through. Willingness to work a flexible schedule to meet job requirements. Ability to multitask and work independently. Excellent organizational skills and attention to detail. Flexibility to travel, if needed, overnight or from clinic site to site. Ability to work events organized by VAC/Westbrook Clinic outside of normal business hours. Commitment to the philosophy, purpose and goals of Valley AIDS Council/Westbrook Clinic.

SPECIAL REQUIREMENTS/QUALIFICATIONS

State of Texas Class \"C\" Driver's License. Active unrestricted LVN license in the state of Texas and registrations consistent with Westbrook Clinic policy and Texas State Law. Certification in Basic Life Support (BLS).

EQUIPMENT USED

Working knowledge of thermometers, EKG machine, Glucometer, Automated External Defibrillator, and blood pressure machine. Requires frequent use of personal computer, including word processing and spreadsheet applications, electronic health record; operate general office equipment and safely operate automobile to travel from site to site.

PHYSICAL

DEMANDs and

WORKING CONDITIONS

While performing the duties of this job, the employee is frequently required to stand and walk for extended periods of time as well as sit and talk and actively listen. Ability to lift or carry up to 30 lbs. with or without assistance. Work is predominantly performed in an office setting, confined spaces where the noise level is usually quiet. This job description should not be interpreted as all-inclusive or as an employment agreement between the employer and employee. It is intended to identify the essential functions and requirements of this job and is subject to change as the needs of the employer and requirements of the job change. Incumbents may be required to perform job-related responsibilities and tasks other than those stated in this specification. Any essential functions of this position will be evaluated as necessary should an incumbent/applicant be unable to perform the function or requirement due to a disability as defined by the Americans with Disabilities Act (ADA). Reasonable accommodation for the specific disability will be made for the incumbent/applicant when possible.

Job Type:

Full-time Pay:

$23.00 per hour

Benefits:

Dental insurance Employee assistance program Flexible schedule Flexible spending account Health insurance Life insurance Paid time off Retirement plan Vision insurance

Work Location:

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Licensed Vocational Nurse - Scribe