Healthcare Documentation Specialist - Jennifer Chang Posted: Jun 21st, 2017 - 12:54 pm
Community Hospital of the Monterey Peninsula is seeking a Healthcare Documentation Specialist.
Position Highlights
• Excellent Pay and Generous Benefits including a Pension and Scholarship Reimbursement
• Excellent Team Orientated Culture
• Free Gym for Employees onsite
• Employee Commissary
• "Best Place to work in Monterey County" 9 years in a row!
This is an onsite position. Pay range is $26.55-$32.21 per hour + shift differential.
Position Summary:
The Healthcare Documentation Specialist (HDS) maintains medical record integrity through interpreting, editing or transcribing dictation by physicians or other healthcare professionals in a multi-specialty acute care facility. Variable specialties, document types, and difficulty of dictation necessitate an advanced level of clinical knowledge, critical thinking, and interpretive ability regarding patient assessment, workup, therapeutic procedures, clinical course, diagnosis, prognosis, as well as demographics such as MRN, work type, and account selection in order to document patient care and facilitate delivery of healthcare.
Position consists of editing/transcribing reports downloaded from eScription program, with greater than 98% accuracy, with a minimum of 1500 lines per day. Accuracy is critical. Drafts must be carefully proofed against the original recording to ensure accuracy. Further editing is always required to produce a comprehensive and accurate report.
This is highly detailed work that requires patience, focus, and attention to detail. HDS listens while reading and editing mostly speech-recognized dictations, or transcribing reports not voice recognized, according to guidelines, including correct terminology, grammar, punctuation, format and style. Applies clinical knowledge in accurately interpreting and capturing patient care encounters, a skill set that must be applied in the challenging setting of new technologies, an expansive and constantly evolving medical language, and an often unpredictable array of practitioners who dictate in haste or speak English as a second language. Consults procedural guides, medical dictionaries, physician lists, reliable internet resources, etc. Accesses patients' medical records to confirm questionable or inaudible information, such as lab results, procedures, etc., as well as inconsistencies and inaccuracies in dictated reports.
HDS carefully proofs the draft to ensure accuracy following editing or transcribing, and then transmits the document into the electronic medical record. HDS is professional, has excellent critical thinking skills, follows directions, is proficient in multitasking, working under pressure, researching, handling telephone calls, managing and assigning reports, making corrections, etc.
Proficient in Microsoft Word, Outlook, EditScript, eMon, Horizon Patient Folder, and Sunrise Clinical Manager.
Experience:
• A minimum of one year of medical transcription experience in acute care facility or equivalent.
• Thorough knowledge of medical terminology.
Education:
• Associate degree or equivalent in work experience and continuing education
Equal Opportunity Employer
LINK/URL: Healthcare Documentation Specialist
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