Medical Documentation Specialist
hace 4 semanas
Job Overview:
As a Medical Documentation Specialist at Pediatric Associates, you will play a crucial role in ensuring the accuracy and completeness of patient medical records. Your primary responsibility will be to provide documentation assistance during the triage process, obtaining medical information directly from patients and documenting it in the progress note.
Responsibilities:
- Review patient records prior to visits to understand the reason for the visit and medical history.
- Verify compliance with GAP Checker metrics and alert Medical Assistants about triage protocols and care gaps.
- Establish a conversation with patients to accurately document medical information, including chief complaints, histories of present illness, medications, medical histories, allergies, hospitalizations, surgeries, family medical histories, and social histories.
- Add templates as required for HPI, ROS, examination, and well visits.
- Change the status of visits to ready for providers.
Qualifications:
- Excellent skills in accurately and completely documenting patient medical histories, understanding provider instructions, and documenting patient medical information.
- Good judgment, organizational ability, initiative, attention to detail, and self-motivation.
- Ability to multitask and work effectively in a high-stress, fast-paced environment.
- Competence to work alone and in a team setting.
- Thorough understanding of confidentiality and non-disclosure according to HIPAA standards.
- Experience with medical terminology.
- Excellent computer and phone skills.
- Impeccable verbal, written, and interpersonal skills.
- Bilingual, fluent in English and Spanish.
- Willingness to make a one-year commitment to work.
- Ability to travel as required for duties or training.
Education and Experience:
- Medical knowledge.
- Basic Word, Excel, PowerPoint skills.
- Excellent redaction skills.
- Able to establish conversations in English and Spanish.
Orientation/Training:
- General Medicine Career completion.
- Medical History Specialists will receive educational materials and training.
- One-week training.
Pediatric Associates is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity, or expression, marital status, genetic information, or any other characteristic protected by law.
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