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Career Ladder Level 2

Healthcare Documentation 

Healthcare Documentation Specialist II

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 preferred (RMT, 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 medical field Preferred

 

Experience:

Over 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.).

 

 


 

Healthcare Documentation Specialist III

Summary:

Healthcare Documentation Specialist, Level 3 transcribes and/or edits patient healthcare documentation dictated by physicians and other healthcare practitioners. Level 3 individuals possess proficient knowledge in the field of healthcare documentation. Nature of work performed crosses all medical specialties in a large acute care setting. Individuals may perform QA tasks, mentor peers and/or assist with projects. AHDI certification preferred (RMT, 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 medical field Preferred

 

Experience:

Over three years healthcare documentation experience at a large acute care facility with knowledge and expertise ranging across multiple medical disciplines and specialties.

 

 


 

Medical Scribe

Description:

This professional tracks with the physician on his rounds and documents medical information for the physician. This is real-time dictation. The clinician may also use a digital recorder and then have his/her MT/MLS extract the information and place into the EMR or clinical system. Often scribes will perform other tasks such as clerical or otherwise.

 

Skills, Training, and Education:
  • Medical background (medical transcription, medical assistant)
  • Accredited medical transcription program (RMT/CMT preferred)
  • Trained as CMA, CNA, LPN, LVN, RN

 

Summary:  

The primary function of this position is the creation and maintenance of the patient's medical record encounter in the Electronic Medical Record which is created under the supervision of the provider. The scribe will document the patient's story, the provider interaction with the patient, the procedures performed, the results of laboratory tests ordered, and other pertinent information. Additional functions may include (under the supervision of the provider) ordering lab/radiology studies, assisting with the patient's disposition, documenting consultations, and notifying the provider when important studies are completed. May work in an ambulatory setting, emergency room, or hospital setting. Data entry is performed real time. Remote options are some times available, but most often the scribe works directly with the provider in the same setting.

 

Educational Requirements:
  • High school diploma, Minimum two year associate degree in the health sciences.
  • CHDS certification preferred. 

 

Experience:

Minimum 1-2 years experience as healthcare documentation specialist.  

 

 


 

Document Integrity 

Healthcare Documentation Integrity Auditor I

Summary:

Healthcare 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 individuals 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 specialties. AHDI certification preferred (RMT, 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:  

Over 3 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.).

 


Revenue Cycle/HIM 

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. Select and sequence appropriate diagnostic codes utilizing ICD-9 CM and/or ICD-10 CM codes. Code the following:

  • Ancillary Coding - ICD-9/ICD-10 diagnostic
  • Ancillary Coding - ICD-9/ICD-10 diagnostic coders

 

Educational Background:
  • High School Diploma or GED Required
  • Registered Health Information Technician Preferred or Bachelor's Degree Registered Health Information Administrator Preferred

 

Experience:

One year experience as a coder preferred.

 

 


 

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. May perform quality monitoring of patient information on transcribed reports.

 

Educational Background:
  • Associate's Degree or equivalent education and experience required.

 

Experience:  
  • Health Information Management (HIM) computer software preferred

 

 


 

HIM Data Analyst

Summary:

Maintains accountability for managing software / data needs and technical services for area of accountability, in collaboration with HIM and Technology and Information Solutions (TIS) staff. Performs the initial analysis of data, develops customized reports to facilitate meaningful interpretation of the data and provides education support to users.

 

Educational Background:
  • Bachelor's Degree or equivalent combination of education and experience required.  

 

Experience:  

2 years of related and relevant experience required, experience with multiple software packages required.

 

 


 

Administrative

Patient Services Rep

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. Is responsible for accurate data input ensuring all financial and regulatory requirements are met. 

 

Educational Requirements:  
  • High school diploma. Minimum of 2 years registration experience in a medical setting is preferred.
  • Knowledge of personal computer and relevant software applications is required.

 

Experience/Skill Sets Required:  
  • Two years working in customer is required.  
  • Knowledge of medical terminology is preferred
  • Knowledge of insurance and third party reimbursement is preferred
  • Excellent customer service skills and computer skills required
  • Must be able to prioritize daily tasks and to work independently
  • Good conflict management and time management skill preferred
  • Ability to understand, interpret, evaluate, and resolve basic customer service issues
  • Knows when to ask for assistance from management
 

 


 

Medical Secretary

Summary:

This position may be located 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 from dictation.   

May also be located in a hospital department such as cardiology, pathology or radiology.  May schedule appointments, exams, and transcribe reports.   

Education Required:

High school diploma. One year certificate medical office training or two year associate degree.  

Experience Required:

 1-2 years preferred

 

 

 

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