Medical Documentation Specialist
4 weeks ago
We are seeking a skilled Medical Documentation Specialist to join our team at West Virginia University Hospitals, Inc. This role is responsible for documenting the physician's or licensed independent practitioner's dictation and/or activities into the medical record.
Key Responsibilities:
- Document patient information, including history of present illness, past medical history, review of systems, medications, social history, family history, allergies, and other elements of the patient chart.
- Transcribe consultations or discussions with family and/or the patient's private physician or the on-call physician.
- Gather laboratory results, radiology results, medical records, and other data for review by the physician or licensed independent practitioner.
- Ensure data is not entered into the EMR, chart, or otherwise incorporated into the medical record until it has been reviewed and approved by the physician's or licensed independent practitioner.
- Communicate with the physician or licensed independent practitioner to ensure timely completion of patient workups.
Requirements:
- High School Diploma or equivalent required.
- West Virginia state criminal background check required, and Federal, if applicable, for DHHR BMS regulated area.
Equal Opportunity Employer: West Virginia University Hospitals, Inc. is an equal opportunity employer and welcomes applications from diverse candidates.
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