ࡱ>  ,bjbj[[ 499$(V V 8d`4pGoooFFFFFFF$xJ*MFooFFF!!!F!F!!n>KB%GQ^C@ F4G<pGc@MlM@BMBo"!_oooFFh fooopGMoooooooooV v: Healthcare Documentation Quality Specialist Job Code: 540011FLSA Status: Non- Exempt Mgt. Approval: C. Williams Date: 7.2016HR Approval: MJG Date: 7.2016JOB SUMMARYThe Healthcare Documentation Quality Specialist has the following responsibilities: Assists with training, coordinating work assignments and distribution, monitors new terminology and error trends, serves as a resource on medical terminology, responds to equipment and transcription system problems, provides support to other Medical Language Specialists as needed, reviews existing procedures and recommends changes, provides input into the review and evaluation of other UWHC Medical Language Specialists Transcribes and edits reports from a large variety of departments and specialty clinics, encompassing all systems of the body and utilizing the most complex surgical terms and medical terminology with a high degree of accuracy. Work is performed independently with limited supervision. Performs investigative work for thoroughness of quality documentation and quality of care and verifies patient information for accuracy and completeness. Accesses electronic medical records on an as needed basis, respecting the patients right to privacy and observing HIPAA guidelines. Recognizes, interprets and evaluates inconsistencies in medical dictation and performs edits and revisions as needed. Clarifies dictation, which is unclear or incomplete. Works cooperatively with departments outside of transcription. Generally works on-site in order to perform the responsibilities listed above, but does work from home on occasion as scheduled. MAJOR RESPONSIBILITIESTRAINING 1. Assist the Transcription Supervisors in developing training and assessment programs designed to: Orient new transcription employees to Medical Transcription. Inform transcription staff of periodic medical terminology and procedure updates. Train transcription staff in use of all transcription software, transcription systems, use of Health Link, and use of other available resources. 2. Develop, prepare and maintain training materials and documents for UW transcription staff and transcription vendors, such as the troubleshooting document, MLS instruction document and QA Criteria document 3. Facilitate training for employee groups of a variety of sizes and skill levels. 4. Respond to followup questions from transcription staff resulting from training programs. 5. Assist in developing a process for evaluating the effectiveness of training using participant feedback and various other levels of evaluation. Work with supervisors to revise programs as necessary. 6. Maintain adequate records of all training activities, training materials, attendees, and program evaluations. 7. Provide on-going user education for enhancements to existing applications. 8. Identify needs and provide individual instruction as necessary. 9. Coordinate with other team members and prepare for implementation of new software and upgrades through testing and manual design. 10. Become an expert on use of ExSpeech Editor, Job Lister, PowerScribe, eScription, Emon, and Surg/Path in order to train and mentor new Medical Language Specialists. B. QUALITY ASSURANCE ACTIVITIES Conduct ongoing evaluation of transcription/documentation sent to the electronic medical record. Continue to train and educate staff and provides feedback to staff on a routine basis regarding quality. SUPPORT Provide first-level support for users. Provide ongoing user education for enhancements to existing applications. Assist in troubleshooting software, hardware, and connectivity problems. Responsible for development of support documentation including user guides and electronic references. D. POLICIES AND PROCEDURES Demonstrate an understanding of policies, procedures, and priorities, seeking clarification as needed. Maintain required records and electronic procedure documents and references, providing reports as scheduled and upon request. Report to work on time, as scheduled. Be dependable and cooperative. Act as a role model in compliance with policies and procedures. E. MEDICOLEGAL 1. Understands and complies with policies and procedures related to medicolegal matters, including confidentiality, amendment of medical records, medical records as legal evidence, informed consent, etc. 2. Meets standards of professional and ethical conduct. 3. Recognizes and reports unusual circumstances and/or information with possible risk factors to appropriate manager. 4. Recognizes and reports problems, errors, and discrepancies in dictation and patient records to appropriate manager. 5. Consults appropriate manager regarding dictation which may be regarded as unprofessional, frivolous, insulting, inflammatory, or inappropriate. ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS.JOB REQUIREMENTSEducationMinimumHigh school diploma Formal training or equivalent in work experience in medical transcription.PreferredWork ExperienceMinimum A minimum of 18 months of medical transcription experience requiredPreferredLicenses & CertificationsMinimum PreferredRequired Skills, Knowledge, and AbilitiesAbility to lead and train other employees Expert knowledge of medical terminology, anatomy and physiology, clinical medicine, surgery, diagnostic tests, radiology, pathology, pharmacology, and the various medical specialties. Expert knowledge of medical transcription guidelines and practices. Excellent written and oral communication skills, including English usage, grammar, punctuation, and style. Ability to work in a team environment and to collaborate with all levels of the Transcription Department. Demonstrated skill in developing, coordinating, and presenting training programs. Ability to use designated reference materials in an expert, appropriate, and efficient manner. Ability to expertly operate designated word processing, dictation, and transcription equipment. Ability to work under pressure with time constraints. Ability to concentrate. Excellent listening skills. Ability to carry out assignments responsibly and independently. Ability to expertly transcribe all document types. Excellent interaction with fellow associates. Ability to identify needs. Ability to develop training aids. Ability to skillfully conduct training programs in accordance with the identified objectives. Ability to write complete and understandable material for training purposes. Ability to maintain and convey a positive attitude and customer service approach to all aspects of training and support of medical transcriptionists.AGE SPECIFIC COMPETENCY (Clinical jobs only) Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients.Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the appropriate boxes below. Next, Infants (Birth 11 months)XAdolescent (13 19 years)Toddlers (1 3 years)XYoung Adult (20 40 years)Preschool (4 5 years)XMiddle Adult (41 65 years)School Age (6 12 years)XOlder Adult (Over 65 years)JOB FUNCTION Review the employees job description and identify each essential function that is performed differently based on the age group of the patient. PHYSICAL REQUIREMENTSIndicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations may be made available for individuals with disabilities to perform the essential functions of this position.Physical Demand LevelOccasional Up to 33% of the timeFrequent 34%-66% of the timeConstant 67%-100% of the timeXSedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.Up to 10#NegligibleNegligible Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. 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