Quality Documentation Specialist (No Experience/Remote Jobs Hiring/Transcription)

Job Description: 

The Quality Documentation Specialist’s (QDS) main function is to deliver high-quality medical documentation and/or transcription services to ScribeAmerica’s partner providers. The QDS role is limited to remote documentation via a secure network. The QDS listens to audio recordings of patient encounters and transcribes the medical record based on that encounter.

The QDS may use a variety of platforms to complete documentation including partner software and hospital electronic medical records. All documentation is reviewed and/or edited by the provider. It is signed with an attestation by the provider that the transcribed chart accurately reflects all work provided by the provider. Remote documentation performed by the QDS may be held to certain asynchronous turnaround times as directed by the client. This is a work from home position.

Duties and Responsibilities

Listen to audio files recording a medical encounter and transcribe proper elements of the patient’s chart including, but not limited to, past history, chief complaint, review of systems, physical exam findings, lab and imaging results, and assessment and plan.
Transcribe any provider dictated diagnoses, prescriptions, and/or instructions for patient follow up.
When applicable, import or transcribe results and/or interpretations from lab and imaging studies into the patient’s record.

Follow documentation standards within the provider preference sheet as directed.
Comply with all governing laws and Company policies including, but not limited to, privacy laws and policies.
Comply with all company and partner policies and procedures.
Ensure documentation productivity meets targets for charts per hour and charts completed per shift.
Properly utilize all software platforms in order to complete documentation.
Attend calls and/or meetings with the respective manager as directed.
Engage in ongoing learning to maintain competency.

Required Education and Pre-requisites

High School Diploma or GRE required
Scribe, typist, transcription or data entry experience is preferred but not required
A typing speed of 60+ WPM is necessary.
Knowledge of medical terminology is preferred.
Ability to work remotely by meeting all hardware and wifi requirements for the position.

Ability to work independently and hold oneself accountable to productivity targets.
Communicate and interface effectively at all levels of the organization.
Demonstrate exemplary work ethic and professionalism.
Possess excellent written communication skills.
Possess strong computer skills – technologically savvy.

Training

Upon hire, the remote scribe is expected to successfully complete a multi-phase training program lasting approximately four weeks, consisting of modular, self-led, and trainer-led coursework. Trainees must meet minimum performance requirements during training.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Frequently required to sit, use hands.
Required to use a keyboard and personal computer regularly.

Specific vision abilities are required, including that required to perform extensive computer-related work.
Must be able to verbally communicate with others and exchange accurate information.
Ability to receive detailed information through oral communication, and to distinguish sound and perceive the nature of sounds at normal speaking levels with or without correction.

Work Environment

The work environment described here is representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

*Must be able to perform all of the essential duties of the job with or without reasonable accommodation

ScribeAmerica provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity and/or expression, national origin, age, disability, genetics, protected veteran status, or any other legally protected group status. In addition to federal law requirements, ScribeAmerica complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

ScribeAmerica expressly prohibits any form of workplace harassment based on race, color, religion, sex, sexual orientation, gender identity and/or expression, national origin, age, disability, genetics, protected veteran status, or any other legally protected group status. Improper interference with the ability of ScribeAmerica’s employees to perform their job duties may result in discipline up to and including discharge.