Healthcare Documentation Specialist I
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About The Position
The Healthcare Documentation Specialist (HDS) Level 1 transcribes, edits, and/or audits healthcare documentation produced by physicians and other healthcare providers in a variety of formats. Level 1 individuals possess entry-level to advanced knowledge and experience and are expected to become/be proficient in all healthcare documentation tasks and work flows while at the same time meeting quality, productivity, and time management expectations per department Standards for level of experience. If at entry level, the nature of work performed is expected to increase as depth and breadth of knowledge, exposure to specialties, and proficiency in healthcare documentation develops. HDSs at this level routinely research questions involved with healthcare documentation. May require a varying level of supervision to resolve routine issues. In addition to, or instead of, performing traditional transcription and/or editing, Level 1 HDSs may also function as a Document Integrity Auditor who ensures the integrity of healthcare documentation created by physicians and other healthcare practitioners. Clinician-created documentation is monitored, measured, and reported on by verifying content and context for critical errors, including inconsistencies, discrepancies, and inaccuracies. As such, the auditor must possess a sufficiently advanced fund of medical knowledge as well as basic computer and Microsoft Office skills and EHR familiarity. An HDS at this level has developed strong, independent research skills involved with healthcare documentation and has strong knowledge of healthcare documentation best practices. The individual in the auditing role is able to resolve more advanced problems independently.
