using a minimum and maximum range of hours for each major job
function and the successful demonstration of identified competencies.
Medical Secretary
USDOL Urban Institute
Work Process Content
On the Job Training
Supports patient access to medical care by relaying information between providers and patients, answering questions about services, and coordinating appointments
10
- Greets callers and in-person visitors warmly and provides courteous service
- Uses sound judgment when dealing with highly sensitive medical information
- Answers patient or provider questions thoroughly and with patience and clarifies misunderstandings
- Connects patients with necessary resources, such as interpreters or translators, when necessary
- Serves as a primary point of contact for the patient and clearly communicates patient needs to the provider team
- Relays information about the providers accepted insurance plans and directs patients to appropriate resources for questions about cost of care
- Answers questions for patients or caregivers regarding physician-ordered referrals for diagnostic appointments, surgeries, or medical consultations
- Demonstrates empathy and compassion in difficult situations
- Receives, documents, and properly follows through on referrals
- Coordinates follow-up between patients and providers on lab results, diagnoses, and appointments
Provides internal support to care provider team
7
- Collects completed patient charts (electronic or hard copy) for office visits and prepares staff for appointments by organizing relevant patient health information, such as reason for visit (including chief complaint), allergies, surgical history, family history, health problems, and immunization records
- Relays information between members of care provider team
- Provides administrative support to physicians, other licensed providers, nurses, and other medical professionals by following directives and seeking clarification when necessary
- Ensures licensed provider productivity by maintaining calendars, professional meetings, conferences, teleconferences, and travel (may be important for smaller offices)
- Updates demographic and insurance information for patients thoroughly and accurately
- Communicates and completes requests between medical offices and staff (faxing or transmitting patient medical records or other information as requested)
- Tracks and directs pipeline of drug refill requests to appropriate medical staff for review and approval. Follows up on prescription refills for patients only as directed by the overseeing licensed independent provider and as permitted by state law
Supports office management including billing, data management, and overseeing supplies
8
- Oversees office supplies inventory by checking stock, anticipating needs, placing and expediting orders, and verifying receipts
- Maintains and controls medical inventory, checking for expired medical supplies
- Coordinates and processes incoming and outgoing mail
- Works with care provider team to complete and submit insurance and other claims forms
- Adopts appropriate acquisition and retrieval systems for medical data
- Maintains current safety data sheets (SDSs) for items in the delivery setting that contain hazardous substances and ensures that SDSs are readily and quickly accessible for staff
- Helps coordinate with appropriate departments to support patient and insurance billing
- Keeps office equipment operating by following operating instructions, troubleshooting breakdowns, maintaining supplies, performing preventive maintenance, and calling for repairs
Applies knowledge of technology, databases, and other software
8
- Possesses basic knowledge of computers and strong data entry skills to capture and process information
- Enters information taken from admission forms into the computer system on a timely basis
- Uses medical software systems, such as Epic, to manage medical records
- Demonstrates proficiency in Word, Excel, and other office processing software as required
- Understands and follows proper procedures to create and maintain medical records, including Electronic Health Record (EHR) documentation
- With supervisor guidance, understands and follows data management laws that protect the confidentiality of patient information, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Genetic Information Nondiscrimination Act (GINA)
- Trains and assists staff with computer usage (applicable to small offices)
- Contributes to and cooperates with the implementation of system improvements
Demonstrates professional and ethical skills and practices
10
- Demonstrates effective time management skills to complete assigned tasks by the deadline
- With guidance from supervisors. identifies challenges in professional and ethical attributes and practices, and develops strategies for addressing them as needed
- Uses professional judgement to prioritize tasks and patient appointments based on severity of patient needs
- Demonstrates knowledge of medical terminology and abbreviations, and uses this knowledge to effectively communicate between patients and care provider team
- Demonstrates conflict resolution skills by identifying the appropriate way to handle different situations
- Updates job knowledge by participating in educational and training opportunities
- Engages in continued training on personal biases and applies these insights to ensure professional and impartial conduct to avoid disparities in equitable health care
- Understands and abides by requirements of the Occupational Health and Safety Administration (OSHA)
- Understands and abides by state law regarding which medically licensed staff members are permitted to inform patients (or their representatives) of unfavorable test results
- Supports and protects the health care community by adhering to the professional standards for safety and quality of care set by state and federal regulatory bodies
Related Instruction Content
Training Provider(s):
Working in a Medical Office
30
Sample learning objectives: Explain the roles and responsibilities of various members of the medical team and the legal scope of practice for each based on the laws in your state. Explain the role of medical referrals, medical orders, and medical records. Explain and differentiate between allowable and prohibited communication and information sharing under HIPAA rules. Explain the role of discretion and confidentiality in working with patients and patient records. Demonstrate the ability to communicate clearly, articulately, and properly through verbal, written, and electronic exchanges. Understand process for gathering documentation and charts of patient-provider encounters in real time for the electronic health records (HER) system. Utilize medical scribing to support communication between care provider team (optional).
Introduction to Computers
30
Sample learning objectives: Demonstrate the ability to log into a computer, access email and calendars, connect to Wi-Fi, and connect to a printer. Explain the different types of internet security threats as well as strategies for identifying, avoiding, and responding to these threats. Explain the importance of passwords and strategies for creating effective passwords. Demonstrate the ability to use word processing software to create letters, reports, and other types of correspondence.
Medical Terminology
40
Sample learning objectives: Explain the etymology of commonly used medical terms. Correctly identify the meaning of Latin prefixes, suffixes, and root terms commonly used in medicine. Describe the function of each of the body’s major systems and use the correct terms to list the component organs and tissues of each system. Identify the medical specialist that treats each of the body’s systems. Correctly identify commonly diagnosed medical conditions associated with each of the body’s major systems. Explain how to find the correct spelling and definition of terms with which the student is not familiar. Understand and effectively use medical abbreviations.
Communication
20
Sample learning objectives: Explain the importance of clear communication and demonstrate the ways in which one can determine if patients or care providers have heard you and understand what you said. Demonstrate the ability to write emails using correct format, punctuation, and spelling and engage in verbal communication using correct sentence structure and grammar to provide instructions to patients regarding their appointment, the location of the medical office, any special preparation needed for the appointment, any records that the patient should bring with them to the appointment, and important office policies such as those related to payment at the time of service and missed appointments. Explain appropriate ways to communicate with people who do not speak English, who are deaf, or who are blind. Demonstrate the ability to send and receive information via electronic means (email, text messages, instant messaging, and facsimile). Demonstrate effective techniques for defusing anger, frustration, and confusion in interactions with patients and colleagues. Demonstrate the ability to use the appropriate medical terminology when communicating with members of the health care team. Describe and demonstrate effective strategies for communicating and coordinating with staff who work in other locations in which the health care provider treats patients. Demonstrate the ability to produce a business letter using standard format, correct spelling, and appropriate grammar.
Scheduling
30
Sample learning objectives: Describe the importance of strategic scheduling, including to accommodate procedures or exams that require patients to not eat or drink for a substantial amount of time before the appointment Explain and demonstrate effective ways to remind patients about upcoming appointments, adhere to missed appointment policies, and reschedule patients when the physician or the patient is unable to keep the scheduled appointment Identify the amount of time that should be allocated for various types of appointments, procedures, consultations, and follow-up appointments Differentiate between appropriate scheduling procedures for routine and emergency exams or procedures Describe various scheduling strategies for physicians who work in multiple offices or who participate in hospital rounds, surgical procedure,s or other activities in a location other than the physician’s office Differentiate between the types of exams or procedures that nurse practitioners, physician assistants, and physicians can provide and describe scheduling strategies for each Demonstrate the ability to assist patients in scheduling tests, procedures, exams, or therapeutic care provided by other medical specialists in different offices or facilities Demonstrate the ability to utilize electronic calendars
Working Effectively with Supervisors and Care Provider Teams
40
Sample learning objectives: Explain the meaning of the term “managing up” and the importance of the medical secretary in helping physicians and direct care providers manage their many responsibilities to patients, other providers, third-party payers, regulatory and government oversight agencies, and office or practice management. Explain the types of providers who work together to manage patient care in private practice, outpatient facilities, and in-patient care facilities. Describe the division of labor within medical offices of different sizes that operate within different types of facilities and rely on different sources of payment for care provided. Describe the multiple demands on care provider time, including regular office hours, emergency requests, hospital rounds, time spent in more than one office or in- patient/outpatient facility, pharmacy requests, entering electronic medical records, completing forms and documents, patient billing, staff management, and professional development. Explain the role of medical secretaries in helping care providers manage the various demands on their time and protecting them against burnout. Demonstrate the use of effective strategies for identifying the wants and needs of supervisors and develop action plans to effectively address those wants and needs. Discuss the importance of communicating with your direct supervisor to understand their needs, the office’s, and areas where the work of a medical secretary can improve personal and team performance. Engage in accurate and informative introspection to identify areas of work excellence as well as areas where more time, attention, or skills are required to better support the medical team or medical office. Demonstrate the ability to request and appropriately receive and respond to constructive criticism about work effectiveness, accuracy, and timeliness. Ask for guidance on expected work products, performance metrics, or performance goals, and evaluate effectiveness in meeting those expectations, goals, or metrics.
Medical Records
20
Sample learning objectives: Explain the importance of maintaining accurate, secure, and private records. Describe appropriate ways to maintain patient privacy through proper records storage. Demonstrate the ability to file electronic and paper records properly based on commonly used filing systems. Explain the benefits of electronic health records. Demonstrate the ability to upload, download, and send and retrieve electronic health records. Explain the need and demonstrate the ability to obtain patient consent to send or receive medical records. Demonstrate the ability to copy and send medical records according to patient or provider instructions. Explain strategies for long-term record maintenance and storage. Demonstrate the ability to provide appropriate medical records to third-party payers to facilitate timely payment for medical services.
Medical Billing and Coding
20
Sample learning objectives: Explain the principles and purpose of medical billing and coding. Differentiate between private-pay patients, private third-party payers, Medicare and Medicaid reimbursements; explain the requirements and restrictions related to each; and demonstrate the ability to provide accurate and complete submissions to third-party payers that result in timely payment. Demonstrate the ability to identify commonly used medical billing codes. Explain the importance of timely billing of patients and third-party payers. Explain the various options that can assist patients in managing and paying medical bills and discuss effective strategies for obtaining payments. Explain appropriate ways to remind patients of their payment responsibilities and differentiate between acceptable collections techniques and prohibited practices that may be perceived by patients as harassment. Demonstrate the ability to transfer delinquent accounts to third-party collection agencies. Demonstrate the ability to prepare complete and accurate bills, including all required supporting information. Demonstrate the ability to enter revenue and expenditures accurately and timely into accounting ledgers or electronic accounting systems. Demonstrate the ability to maintain accurate records regarding documents and information provided to third-party payers, as well as payments made by third parties and balances due that must be charged to patients.