Job Information
Tri-County Health Care Documentation Assistant in Wadena, Minnesota
Astera Health currently has an opening for a Documentation Assistant. This position works alongside a medical provider to provide annotation of information for the treatment of patients. If you have a passion for helping others and a commitment to excellence, we’d love to hear from you! This is a great opportunity for anyone interested in joining the medical field!
This position is 40 hours weekly, Monday - Friday, 8:00am - 5:00pm. Astera Health offers a comprehensive benefits package including health, dental, vision, life and retirement. We also support work-life balance through benefits such as paid time off, short and long-term disability and our employee wellness initiative.
Responsibilities of this position include, but are not limited to:
Accompanies the practitioner into the patient examination area in order to transcribe findings in real time as the provider evaluates the patient
Documents the following items, as dictated:
History of the patient’s chief complaint as given by the patient and communicated by provider.
Review of Systems (ROS) and physical examination as given by patient and communicated by provider.
Patient orders, laboratory tests results/needed, imaging tests results/needed, etc.
Completes procedures notes on behalf of the provider as directed
Enters documentation on patient progress as directed by provider
Lists proper diagnosis/level of service as well as any discharge and/or follow-up instructions as dictated by provider
Follows documentation and compliance standards
Competencies required include:
Demonstrate the knowledge and skills necessary to document patient care as dictated by a provider in a legible and clear manner, follow all local, state and federal guidelines for documentation
Demonstrate an ability to maintain confidentiality and privacy in accordance with governing HIPAA regulations
Knowledge of medical terminology, anatomy and physiology
Ability to work well under pressure and maintain attention to detail in order to accurately document encounter
Demonstrated observation, listening, interpersonal and clarification skills in order to interact positively and productively with provider and patient
Demonstrated knowledge of computers and technology
Excellent verbal and written communication skills
Education and experience required:
High School Diploma or GED
2-years related experience preferred
ICD-10/CPT/HCPCS education preferred
Astera Health is an Equal Opportunity/Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.
