The responsibilities of this job include, but are not limited to the following :

• Transcribing patient encounter dictation (verbatim and edited for new hires) and returning it to the Physician or Extender and respective trainer or Medical Director for inspection / review;
• Purposefully questioning dictations, coding, and medical necessity, facilitating understanding of the correction process and medical / trauma protocols as well as ICD-10, E / M, and other CPT guidelines;
• Ensuring all trainees understand the different work types in the dictation system, how to run protocols in the medical record system, and the significance of dictation procedures;
• Providing comments to trainers and trainees regarding brevity and efficiency; sending edited versions of dictations to demonstrate same without losing pertinent documentation;
• Assisting all trainers and Physician and Extenders with dictation behavior modification as needed in order to facilitate meeting company efficiency goals, CDI initiatives, and E / M guideline requirements;
• Offering suggestions to meet and / or adjust level of E / M service using the protocols when necessary;
• Providing Physicians and Extenders detailed documentation and explanations of any deficiencies in the clinical records and / or coding;
• If needed, requesting and transcribing corrections, addenda, and re-dictations and submitting back to trainers or Physicians and Extenders for review;
• Uploading dictation into the medical record once satisfied that all requirements are being or will be met and forwarding coding change requests to the coding department as needed for each chart transcribed or reviewed.

Minimum education and professional requirements include, but are not limited to, the following :

• High school diploma required;
• Certified Professional Coder (CPC) certification required with emphasis on E / M auditing preferred;
• Formal training through an accredited transcription program preferred;
• Seasoned knowledge of medical terminology, anatomy and physiology, disease processes, signs and symptoms, medications, and laboratory values, etc.;
• In-depth or broad knowledge of a specialty or specialties as appropriate;
• Knowledge of medical transcription guidelines and practices;
• Excellent skills in English usage, grammar, punctuation, and style;
• Excellent verbal and written communication skills;
• Knowledge of basic coding and CDI principles;
• Ability to use an extensive array of professional reference materials;
• Ability to operate a PC and transcription equipment and other equipment as specified;
• Ability to work independently with minimal or no supervision;
• Proficiency in a variety of Microsoft applications and operating software products and transcription-specific software products;
• Ability to work under pressure with time constraints;
• Excellent hand, eye, and auditory coordination, and listening skills;
• Ability to understand and apply relevant legal concepts (e.g., confidentiality);
• Ability to sit for extensive periods of time;
• Ability to lift moderately heavy items (20 to 40 pounds).

Last updated : 2024-02-24