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Career Map: Level 2

Healthcare Documentation Specialist 2 

Summary:

Healthcare Documentation Specialist, Level 2, transcribes and/or edits patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 2 individuals possess proficient knowledge within certain areas of expertise and can meet departmental expectations. Nature of work performed is for a specific medical specialty or at a community hospital level with limited dictators and/or types of documentation produced. AHDI certification is preferred (RHDS, CMT, or CHDS).

 

Educational Background:
  • High school diploma or GED required
  • Vocational/technical healthcare documentation/transcription training required
  • Demonstrates continued educational credits in the medical field preferred
     
Experience Required:
  • More than one year healthcare documentation experience within a setting with limited scope such as a community hospital, emergency, ambulatory or certain medical specialty (radiology, cardiology, neonatal, a specific clinic, etc.)

 


Medical Scribe 

Summary:

The medical scribe plays an integral role in allowing healthcare providers to focus directly on patients in the clinical setting. By assuming responsibility of the interaction between patient and provider for documentation within the electronic health record, the scribe contributes to overall efficiency and patient satisfaction. Scribes are discreetly and unobtrusively present for the encounter but do not touch the patient or engage in any type of patient care. All scribe-created documentation is reviewed and/or edited by the provider, who is the one ultimately responsible for its content. An attestation is added to all documents to ensure that the scribed chart accurately reflects all work performed by the provider. Scribes may perform other clerical duties as needed. Training and ongoing support to be provided. 

 

Educational Background:
  • College graduate, student enrolled, or interested in pursuing a healthcare professional career; exceptions made for individuals with equivalent experience

 

Experience Required:
  • Working knowledge of medical terminology
  • Medical background (healthcare documentation specialist, medical assistant, medical student) preferred
  • Excellent verbal and written communication skills
  • Typing speed minimum of 65 WPM

Clinician-Created Documentation Integrity Auditor 1 

Summary:

Clinician-Created Documentation Integrity Auditor, Level 1, audits and ensures the integrity of healthcare documentation created by physicians and other healthcare practitioners. Quality is monitored, measured, and reported on by verifying content and context for inconsistencies, discrepancies and inaccuracies. Level 1 auditors possess proficient medical knowledge, basic computer and Microsoft Office skills, and EHR familiarity. Nature of work performed may be limited in scope within community hospital settings, emergency departments, or a specific medical specialty. AHDI certification is preferred (RHDS, CMT, or CHDS).

 

Educational Background:
  • High school diploma or GED required
  • Vocational/technical healthcare documentation/transcription course preferred
  • Demonstrates continued educational credits in the healthcare documentation/medical field required
     
Experience Required:
  • More than three years’ healthcare documentation experience within a setting with limited scope such as a community hospital, emergency, ambulatory or certain medical specialty (radiology, cardiology, neonatal, etc.)  

Coder I 

Summary: 

Reports to the Ancillary Coding Manager. Reviews all pertinent documentation, including but not limited to physician documentation, nursing documentation, laboratory and radiology reports, treatment records, and other documentation within the electronic medical record. Selects and sequences appropriate diagnostic codes using ICD-9 CM and/or ICD-10 CM codes: Ancillary Coding – ICD-9/ICD-10 diagnostic and Ancillary Coding – ICD-9/ICD-10 diagnostic coders.

 

Educational Background:
  • High school diploma or GED required
  • Registered Health Information Technician preferred
  • Bachelor's degree or Registered Health Information Administrator preferred

 

Experience Preferred: 
  • One year of experience as a coder

HIM Technician 

Summary:

Under general direction, accesses, inputs and retrieves information and problem solves using various computer systems. Acts as liaison for physician offices. Responsible for verification of completed dictation into system. Inputs and retrieves information and problem solves using various computer systems. Acts as liaison for physician offices. Responsible for verification of completed dictation into system. Responsible for Release of Information (ROI) and Birth Registry (BR). In ROI, responsible for providing superior customer service while reviewing and processing information requests from patients, physicians and other medical professionals, insurance companies and others. In BR, responsible for assisting mothers to complete required documentation for the State Department of Vital Records. Maintains confidentiality of medical records in accordance with HIPAA regulations.

 

Educational Background:
  • Associate's degree or equivalent education and experience preferred
  • Attain state certification for the department of vital records within six months required
     
Experience Preferred:
  • Health Information Management (HIM) computer software
  • Two years of related records management experience
  • One year of customer service experience, preferably in an acute care setting
     

Medical Secretary 

Summary: 

This position may be in a physician's office where the medical secretary may schedule surgery, tests, or appointments. May be required to enter data in the EHR or transcribe dictation. May also be in a hospital department such as cardiology, pathology, or radiology. May schedule appointments, exams, and transcribe reports.  

 

Educational Background:
  • High school diploma
  • One-year certificate in medical office training or two-year associate’s degree

 

Experience: 
  • One to two years preferred

Patient Services Representative 

Summary: 

The initial point of contact for patients entering the health system through various portals within the organization. Acts as ambassadors for customer service, service recovery, and follow through for patient satisfaction. Responsible for accurate data input, ensuring all financial and regulatory requirements are met. 

 

Educational Background: 
  • High school diploma

 

Experience/Skill Sets Required: 
  • Knowledge of personal computer and relevant software applications
  • Two years working in customer service
  • Excellent customer service and computer skills
  • Must be able to prioritize daily tasks and to work independently
  • Ability to understand, interpret, evaluate, and resolve basic customer service issues
  • Knows when to ask for assistance from management

 

Experience/Skill Sets Preferred: 
  • Minimum of two years’ registration experience in a medical setting
  • Knowledge of medical terminology
  • Knowledge of insurance and third-party reimbursement
  • Good conflict management and time management skills

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