A Record & Transcription Management Apprentice is representative of an employee with a tenure of 0 to 6 months within the Records & Transcription Management department.
The primary responsibilities of an Apprentice are to produce and manage record summaries from medical records at the direction of associate physician experts. They will also perform quality assurance protocols on preliminary record summary drafts and obtain associate physician expert approval to finalize summaries for purposes of life care plans.
Essential Job Functions
Meet or exceed established performance metrics during the initial 30-day tenure:
o
8-10 record reviewed pages per day/40-50 record reviewed pages per week
o
Meet or exceed established performance metrics between 30-60 days of tenure:
o
10-12 record reviewed pages per day/50-60 record reviewed pages per week
o
Meet or exceed established performance metrics between 60-90 days of tenure:
o
12-15 record reviewed pages per day/60-75 record reviewed pages per week
o
Meet or exceed the established performance metric of 15 record reviewed pages per day after 90-days of tenure.
Meet the established performance metric of 5 errors per week after 90-days of tenure.
Attain an overall average rating of Meets Expectations or above in the 30/60/90 day and 6-month performance evaluations.
Possess a solid understanding of medical terminology, procedures, and diagnostics.
Possess the ability to independently submit and finalize a medical record summary within 6 months of tenure.
Possess the ability to in-house records and create a chronological record summary in its entirety within 6 months of tenure.
Possess a clear understanding of the production of a record summary to include additional records, expert submission, and finalization.
Be knowledgeable of the department style sheet and finalization checklist for implementation in the Quality Assurance process.
Be able to follow and implement new processes and workflows introduced within the record summary process.
- Producing record summaries from medical records.
- Working with dictation transcriptions.
- Developing and maintaining proficiency with the use of the company’s proprietary workflow and
information management system.
- Provide feedback regarding other medical transcriptionist/scribes to help improve their quality and
accuracy.
- Providing constructive input to help improve systems and processes.
- Proofing qualitative sections of life care plans and other damages valuation documents.
- Formatting to conform documents to style sheet frameworks.
- Other duties which may be assigned as needed.
Minimum Requirements
- 6+ months of professional experience working in a medical office, doctor’s office, or a medically related
field OR;
- 60 accredited hours with a major of Science in Biology, Anatomy, and/or Chemistry OR;
- Experience in a medical transcription role OR;
- Intermediate experience transcribing medical dictation in a medical office, doctor’s office or a medically
related field.
- Intermediate level of proficiency in grammatical skills.
- Intermediate level of proficiency with Microsoft Office (Word, Excel and Outlook), Adobe Reader and web based systems.
- Maintains HIPAA patient confidentiality standards for medical information.
- Excellent professional written and verbal communication skills.
- Ability to work in a sedentary position for the duration of the assigned work schedule.
- Typing 50 WPM
Preferred Requirements
- Bachelor’s Degree of Biology, Anatomy, and/or Chemistry.
- Preferred in a discipline requiring familiarity with medical terminology or;
- Medical Scribe background, highly preferred. Equivalent combination of education, training, & experience.
- Intermediate knowledge in human anatomy, physiology, major disease processes, pharmacology, and the
metric system for purposes of: identifying specific clinical findings, supporting diagnoses, and
substantiating listings and additional diagnoses in medical records
- Intermediate knowledge of medical codes and descriptions, including CPT, HCPCS, ICD-9/10 CM, MS-DRG.
- Demonstrated ability to transcribe history & physical reports, operative reports, and consultation reports
for multi-specialties to include, but not limited to: Gynecology, General Surgery, Ophthalmology, Plastic
Surgery, Oral Surgery, Urology, Hematology/Oncology, Nephrology, Cardiology, General Medicine,
Pulmonary, Endocrinology, Cardiothoracic Surgery, Vascular Surgery, Neurosurgery, Neurology,
Otolaryngology, Orthopedics and Physical Medicine.
- Demonstrated ability to review and edit transcriptions for spelling, grammar, clarity and correct medical
terminology.
Work Schedule
- 5 day/40-hour work week: Mon - Fri 8:30am - 5:30pm
- Overtime may be needed based on business needs.
Work Environment
The work environment at Physician Life Care Planning is a professional office setting. Reasonable
accommodations may be made to enable individuals with disabilities to perform essential functions.
Physician Life Care Planning’s Core Values: Commitment to Excellence, Superlative Expertise, Integrity,
Ownership, Professionalism, Problem-Solving and Customer Centricity.
Physician Life Care Planning is an equal opportunity employer.
Confidentiality
Records & Transcription Management Associates must adhere to Federal HIPAA Regulations and willing to sign
a Confidentiality Agreement
