Clinical Documentation Specialist

DHR Health; Edinburg (TX); On-site; USD 36,000 - 48,000; Full time

Job summary

DHR Health in Edinburg, TX is seeking a Documentation Specialist to assist physicians with chart documentation, accompany rounds, and record observations in the EMR. The role requires Medical Terminology, MS Office skills, and strong written and verbal communication.

Previous hospital or physician office experience is preferred. You will support patient care workflows and ensure accurate data entry in a fast-paced environment.

Qualifications

• High School graduate or equivalency preferred.
• Medical Terminology required.
• Proficient with Microsoft Office suite.
• Strong written and verbal communication skills required.

Responsibilities

• Promotes the facility mission, vision and values by effectively communicating them to others.
• 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 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

Skills

Medical Terminology

Microsoft Office

Written Communication

Verbal Communication

High School Diploma

Education

High School Diploma or Equivalent

Tools

EMR System

Microsoft Office Suite

Job description

DHR Health in Edinburg, TX is seeking a Documentation Specialist to assist physicians with chart documentation, accompany rounds, and record observations in the EMR. The role requires Medical Terminology, MS Office skills, and strong written and verbal communication.

Previous hospital or physician office experience is preferred. You will support patient care workflows and ensure accurate data entry in a fast-paced environment.