Medical Transcriptionist

The Medical Transcriptionist is a medical language specialist who transcribes and interprets dictation by physicians and other healthcare providers in order to document patient care. This position is also routinely involved in research of questions and in the education of others involved with patient care documentation.

Essential Duties and Responsibilities:

• Produces medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
• Performs data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
• Returns dictated hospital and clinic reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records.
• Distinguishes between homonyms, and recognize inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.
• Identifies mistakes in reports and works with physicians to obtain the correct information.
• Assists patients and others with the release of medical records.
• Works with OB patients to complete necessary paperwork for birth certificates and filing paternity affidavits for new births.
• Assists with maintaining the IHIE inbox, provider direct email addresses for Meaningful Use, and setting up providers for Docs 4 Docs.
• Assists hospital outpatient departments with creating and maintaining patient packets and medical records.
• Participates in call time on weekends and holidays for medical transcription and other Health Information Management (HIM) records as needed.
• Protects patient privacy and confidentiality in accordance with HIPAA and privacy laws.
• Ensures patient satisfaction, including troubleshooting when there is a complaint and developing process improvements to prevent reoccurrences.
• Demonstrates clear ownership of workplace and patient safety.
• Report mistakes, near misses, adverse events and quality and safety concerns.
• Participates in the development and implementation of safety and quality improvement activities.
• Other duties as may be assigned.

Job Requirements

Education: High School Diploma or GED required.

Certification/Licensure: Certified medical transcriptionist (CMT) or certified healthcare documentation specialist (CHDS) preferred.

Experience: Three (3) years of previous experience as a Medical Transcriptionist required. Knowledge of medical terminology, anatomy and physiology. Knowledge of medical transcription guidelines and practices. Excellent skills in English usage, grammar, punctuation, and style. Ability to: use an extensive array of professional reference materials; operate word processing, dictation and transcription equipment; work independently with minimal or no supervision; work under pressure with time constraints. Excellent communication skills, especially listening, required.

Physical Requirements: Frequently sitting and typing for long periods of time. Occasionally lift up to 25 lbs. Ability to bend, stoop and reach. Good hearing acuity for transcribing dictation.