Job Description

Healthcare Documentation Specialist Lead
Job CategoryClerical
ScheduleFull time
Shift1 - Day Shift

SUMMARY:

The Lead healthcare documentation specialist (HDS) must be fully competent in the HDS Level 2 essential functions, knowledge, skills, and abilities. 

 

This individual is responsible for ensuring effective day-to-day transcription operations, delivering quality services within turnaround times, including the use of outsourced transcription services when needed.  Assists manager in assignment of all tasks and work flows to HDSs who transcribe, edit, or audit healthcare documentation.  Researches questions and educates others.  Is knowledgeable about all department equipment and computer hardware and software used and can troubleshoot issues independently.  Resolves complex problems independently and assists in guiding and training other HDSs.  In conjunction with manager, performs on-going quality assurance reviews that provide consistent, reliable, and measurable results expected to enhance the skills and knowledge of HDSs and improve patients’ medical records.  Acts as a peer interviewer.  Assists in evaluating employee performance.  Assists in preparation of staff work schedules.  Engages in continuous process improvement. 

 

Maintains appropriate records, including the editing of payroll documents.  Receives a variety of assignments with different requirements from different originators.  Maintains an active presence with facility, Revenue Cycle, and department teams.  Maintains and follows organizational and departmental policies and procedures.  Complies with local, state, and federal employment laws affecting employees.  Responsible for ensuring that all programs are administered according to facility and departmental standards, policies, procedures, and applicable regulatory compliance. 

 

May perform transcription and auditing responsibilities when needed.  Assumes a share of department on call as needed.

 

ESSENTIAL FUNCTIONS:

Monitors and directs HDS staff.

Assists in the training of staff in 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 and instructs staff in the operation of computers and various applications involved in the creation of healthcare and related departmental documents, including patient demographics, transcription application, Microsoft Office applications, and the electronic health record (EHR).

Utilizes with care and instructs staff in the appropriate care and maintenance of all equipment provided for use by Tucson Medical Center Healthcare (TMCH).  May maintain records of TMCH equipment.

Develops training materials to assist HDS staff in the function of their duties.

Writes standard work for processes and procedures and updates them as needed.

Develops reports and maintains activity records for management review.

Ensures that institutional policies and procedures for maintenance of medical records are followed.

Adheres to TMCH organizational and department-specific safety and confidentiality policies, as well as values and standards.

Performs all other HDS Level 2 essential functions.

Assumes a share of department on call availability after hours.

Performs other related duties as assigned.

 

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) to five (5) years of related healthcare documentation specialist experience required, preferably in an acute care setting and in a lead, supervisory, and/or quality assurance assessor capacity.

LICENSURE OR CERTIFICATION:  Certified healthcare documentation specialist (CHDS) credential preferred.

 

Application Instructions

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