Job Description
Summary The Healthcare Documentation Specialist (HDS) Level 1 transcribes, edits, and/or audits healthcare documentation produced by physicians and other healthcare providers in a variety of formats.Level 1 individuals possess entry-level to advanced knowledge and experience and are expected to become/be proficient in all healthcare documentation tasks and work flows while at the same time meeting quality, productivity, and time management expectations per department Standards for level of experience.If at entry level, the nature of work performed is expected to increase as depth and breadth of knowledge, exposure to specialties, and proficiency in healthcare documentation develops.HDSs at this level routinely research questions involved with healthcare documentation.May require a varying level of supervision to resolve routine issues.
In addition to, or instead of, performing traditional transcription and/or editing, Level 1 HDSs may also function as a Document Integrity Auditor who ensures the integrity of healthcare documentation created by physicians and other healthcare practitioners. Clinician-created documentation is monitored, measured, and reported on by verifying content and context for critical errors, including inconsistencies, discrepancies, and inaccuracies.As such, the auditor must possess a sufficiently advanced fund of medical knowledge as well as basic computer and Microsoft Office skills and EHR familiarity. An HDS at this level has developed strong, independent research skills involved with healthcare documentation and has strong knowledge of healthcare documentation best practices.The individual in the auditing role is able to resolve more advanced problems independently.
Essential Functions Utilizes a basic-to-advanced fund of knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, laboratory values, surgical procedures, and specialties to transcribe, edit, or audit healthcare documentation produced in a variety of formats in an accurate and timely manner.
Utilizes knowledge in use of patient demographics as provided by various applications and interfaces.
Utilizes transcription applications as well as Microsoft Office applications and the electronic health record (EHR) effectively.
Complies with all quality, productivity, and time management expectations in all tasks and work flows per department Standards for level of experience.
Competently maintains all equipment provided for use by Tucson Medical Center Healthcare (TMCH).
Adheres to TMCH organizational and department-specific safety and confidentiality policies, as well as values and standards.
Performs related duties as assigned.
Pathology Support Maintains phones and responds to requests for information. Manages morgue book daily, ensuring paperwork is complete and accurate for each decedent, resolving errors as needed. Follows up with family or authorized party to release decedents timely. Completes release paperwork. Provides support and assists pathologists as requested. Manages face sheets for billing purposes, coordinates and completes outside consultant requests, pulling blocks and slides as needed for send out or further pathologist review. Prepares various tumor board information each week and assists with legal preservation. Pulls samples to send out to other labs then records when samples are returned; enters or retrieves data from computer files, scans and labels a variety of samples.
Minimum Qualifications EDUCATION: High school diploma or general education degree (GED) required. Associate’s degree in a related field and/or vocational/technical healthcare documentation/transcription training preferred.
EXPERIENCE: Three (3) years of related healthcare documentation transcription experience in an acute care setting preferred.Will consider new graduates with zero (0) years of experience.
LICENSURE OR CERTIFICATION: None required.
Knowledge, Skills And Abilities - Knowledge of medical terminology, anatomy, physiology, disease processes, signs and symptoms, medications, laboratory values, surgical procedures, and specialties.
- Knowledge of medical transcription guidelines and best practices.
- Skill in English language usage, grammar, punctuation, style, and editing.
- Skill in reading and listening to ensure comprehension.
- Ability to use a wide array of professional reference materials in both printed and electronic format.
- Knowledge and use of Microsoft applications, EHR software, and transcription applications; general computer, keyboarding, and mouse usage.
- Ability to effectively navigate the EHR.
- Knowledge of, and ability to , identify patient safety and risk management issues within healthcare documentation.
- Ability to understand and compare information entered into the medical record by numerous sources, and ability to accurately assess that information is consistent and appropriate for the patient.
- Ability to process, assess, and/or decipher information entered into the EHR, including the ability to research to verify information that may appear incorrect, incomplete, or ambiguous.
- Ability to multi-task (perform more than one task at a time and/or quickly switch back and forth between tasks) while working under pressure of time constraints.
- Ability to work independently with a varying level of supervision, working toward minimal supervision.
- Ability to concentrate and pay attention to detail.
- Ability to understand and apply relevant medicolegal concepts such as confidentiality.
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