Clinical Documentation Specialist

DHR Health; McAllen (TX); Presencial; USD 42.000 - 54.000; Jornada completa

Descripción de la vacante

DHR Health in McAllen, TX is seeking a Documentation Specialist to assist physicians in complete chart documentation, both paper and EMR-based. The role involves accompanying physicians during rounds and ensuring accurate observation notes are recorded during patient encounters.

The ideal candidate has high school education, medical terminology knowledge, and proficient computer skills with MS Office; bilingual in English/Spanish is preferred. Experience in healthcare settings is beneficial.

Formación

• High School graduate or equivalency preferred.
• Medical Terminology knowledge required.
• CNA or Medical Assistant certification from an accredited school preferred.
• Computer skills required with knowledge of Microsoft Office suite.
• Good written and verbal communication skills required.
• Bilingual – English/Spanish.

Responsabilidades

• 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 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

Conocimientos

Medical Terminology

Computer Skills

Bilingual – English/Spanish

Strong communication

High School diploma

Educación

High School diploma or equivalent

CNA/Medical Assistant certification

Herramientas

Microsoft Office

Descripción del empleo

DHR Health in McAllen, TX is seeking a Documentation Specialist to assist physicians in complete chart documentation, both paper and EMR-based. The role involves accompanying physicians during rounds and ensuring accurate observation notes are recorded during patient encounters.

The ideal candidate has high school education, medical terminology knowledge, and proficient computer skills with MS Office; bilingual in English/Spanish is preferred. Experience in healthcare settings is beneficial.