Healthcare Documentation Specialist I
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.
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.
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.