Healthcare Documentation Specialist & Medical Scribe

DHR Health; McAllen (TX); On-site; USD 42,000 - 64,000; Full time

Job summary

DHR Health is seeking a Documentation Specialist to assist physicians with complete documentation of patient charts. The role involves accompanying physicians on rounds, recording observations in EMR, and ensuring accurate documentation for each patient encounter.

Qualified candidates will have medical terminology knowledge, a high school diploma or GED, and preferably CNA/Medical Assistant certification. Bilingual English/Spanish and strong computer skills are required.

Qualifications

• High School graduate or equivalency is preferred.
• Medical Terminology 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.

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

Skills

MS Office proficiency

Bilingual English/Spanish

Written communication

Verbal communication

Education

High School diploma or GED

CNA or Medical Assistant certification

Tools

EMR system

Job description

DHR Health is seeking a Documentation Specialist to assist physicians with complete documentation of patient charts. The role involves accompanying physicians on rounds, recording observations in EMR, and ensuring accurate documentation for each patient encounter.

Qualified candidates will have medical terminology knowledge, a high school diploma or GED, and preferably CNA/Medical Assistant certification. Bilingual English/Spanish and strong computer skills are required.