Clinical Documentation Specialist (EMR & Patient Encounters)

DHR Health; McAllen (TX); On-site; USD 45,000 - 60,000; Full time

Benefits offered by this job

Health benefits

Job summary

DHR Health is seeking a Documentation Specialist to support physicians in documenting patient charts. You will accompany physicians on rounds, record observations, and ensure accurate entries in the EMR or paper records. The role emphasizes precise data capture and collaboration with care teams.

The ideal candidate has medical terminology knowledge, strong communication skills, and bilingual English/Spanish abilities. Proficiency with Microsoft Office and patient data handling is essential.

Qualifications

• High school diploma or equivalent preferred.
• Medical Terminology required.
• CNA or Medical Assistant certification preferred.
• Computer skills with Microsoft Office proficiency required.
• Strong written and verbal communication skills required.
• Bilingual – English/Spanish.

Responsibilities

• Assist physicians with complete documentation of patients' charts.
• Record physician observations and comments in paper or EMR.
• Attend hospital rounds and consultations with physicians as needed.
• Coordinate between physicians and staff; manage calls and communications.
• Document consultations with patients’ outside providers as required.
• Take vital signs and room patients as needed.
• Document diagnoses, treatment plans, and discharge information.
• Support documentation across the patient care cycle.

Skills

Medical Terminology

Bilingual English/Spanish

Communication skills

Microsoft Office

Attention to detail

Education

High School diploma or equivalent

CNA or Medical Assistant certification

Tools

EMR system

Microsoft Office

Job description

DHR Health is seeking a Documentation Specialist to support physicians in documenting patient charts. You will accompany physicians on rounds, record observations, and ensure accurate entries in the EMR or paper records. The role emphasizes precise data capture and collaboration with care teams.

The ideal candidate has medical terminology knowledge, strong communication skills, and bilingual English/Spanish abilities. Proficiency with Microsoft Office and patient data handling is essential.