Documentation Clerk jobs in Brownsville, TX

DHR Health - US:TX:Brownsville - Days

Summary:

POSITION SUMMARY :

The Primary role of a medical “Clinical Documentation Specialist” is to assist the physician with the complete documentation of patients’ charts. Clinical Documentation Specialists accompany the physician as he/she examines and interviews patients and then records the physician’s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the practice uses. Clinical Documentation Specialist will accompany physician on hospital rounds and consultations if required. All information is recorded in the presence of a physician, as dictated by the physician.

POSITION EDUCATION/QUALIFICATIONS :

¨ High School graduate or equivalency is preferred.

¨ Medical Terminology required.

¨ Excellent customer service skills.

¨ Computer skills required with knowledge of Microsoft Office suite.

¨ Good written and verbal communication skills required.

¨ Bilingual – English/Spanish.

JOB KNOWLEDGE/EXPERIENCE :

¨ One ( 1 ) year experience in a hospital or physician office setting is preferred

¨ Previous experience as a medical scribe preferred

¨ Demonstrates proficiency in Microsoft Office applications

¨ Previous experience with an EMR system preferred

¨ Must have excellent customer service and organizational skills

Requires reasoning ability and good independent judgment

Responsibilities:

POSITION RESPONSIBILITIES :

¨ Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices

¨ Keep track of laboratory tests, medications, and radiology tests ordered by the physician

¨ Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records)

¨ Coordinate communication between physicians and staff, make and answer telephone calls

¨ Document any consultations the physician makes to a patient’s personal doctor, family members, on-call physician, or other members of the medical community

¨ Take vital signs and room patients as needed

¨ Accompany provider to hospital to document consults or hospital rounds as needed

¨ Provide patients with updates about waits and delays

¨ Document all procedures done by the physician, as dictated by the physician

¨ Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient

¨ Other duties as assigned

Other information:

LINES OF RESPONSIBILITY :

Physician, Chief Ambulatory Officer, Practice Administrator, Manager

CUSTOMER SERVICE:

Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Compassion, Accountability, Respect, Excellence through Knowledge and Safety & Social Conscience.