Data Entry Medical Records
Resume:
Yesenia Gomez
Prescott Valley, AZ 86314
adzxc6@r.postjobfree.com
SKILLS
Medical Billing
Charting Expertise
Understands Medical Procedures
Advanced Anatomy Knowledge
HIPAA Compliance
Patient Feeding
Patient Toileting
Documentation Procedures Expert
Grooming and Bathing Assistance
Inventory and Supply Management
Able to Lift [Number] Pounds
Patient Skin and Nail Care
Proper Sterilization Techniques
Professional Bedside Manner
Dictation and Transcription
Completing Insurance Forms
Time Management
Multitasking and Prioritization
Problem Anticipation and Resolution
Patient Relations
Multi-line Telephone System
Operation
Operating EKG Equipment
EXPERIENCE
Critical Thinking
Wound Care
Updating Medical Records
Routine Laboratory Testing
Appointment Scheduling
Social Perceptiveness
Diagnostic Testing
Treatment Room Preparation Decision Making
Clear Communication
Procedure Assistance
Coordinating Drug Refills
X-Ray Processing
Check-In and Check-Out Procedures Pharmacy Relations
Cleaning and Organizing
Clinical and Operational Judgment Medication Administration
Examination Preparation
Cleaning and Sanitizing
Supply Management
Thumb Butte Medical Center - Medical Assistant
December 2020-January 2023
●Collaborated with local pharmacies to resolve and clarify issues with patient medication.
●Relayed messages from patients to physicians about concerns, condition updates or refill requests to facilitate treatment.
●Contacted pharmacies to submit and refill patients' prescriptions.
●Maintained inventory, vaccination and product expiration logs to record updated documentation for tracking purposes.
●Responded to patient callbacks and phone-in prescription refill requests.
●Assisted with diagnostic testing by collecting and packaging biological specimens for internal and laboratory analysis.
●Labeled and completed lab requisitions using ICD and CPT coding.
●Prepared treatment rooms for patients by cleaning surfaces and restocking supplies.
●Educated patients about medications, procedures and physician's instructions.
●Cleaned and maintained medical equipment following procedures and standards.
●Interviewed and engaged patients to obtain medical history, chief complaints and vital signs.
●Participated in team meetings to improve workflows and contribute to improving patient population outcomes.
●Organized charts, documents and supplies to maintain team productivity.
●Measured vital signs and took medical histories to prepare patients for examination.
●Assessed, documented and monitored vital signs for patients within outpatient setting.
●Scheduled appointments for patients via phone and in person.
●Followed principles of asepsis and infection control to meet patient safety guidelines.
●Documented notes during patient visits.
●Incorporated outside records into charts and EHR.
●Secured patient information and maintained patient confidence by completing and safeguarding medical records.
●Administered rapid tests for COVID and strep to help clinical staff assess conditions.
Thumb Butte Medical Center - Medical Scribe
December 2020-January 2023
●Translated medical jargon and short-hand data into correct terminology.
●Informed doctor of urgent patient needs per nursing progress notes.
●Evaluated charts, documents and orders and made timely corrections.
●Documented and initiated tests, scan and other orders.
●Used medical record software every day and developed advanced skills.
●Transferred transcribed materials into electronic health records system.
●Input details about patient histories, physical examinations, medications and other information into physical or electronic charts.
●Demonstrated knowledge of terminology for multiple medical specialties, consistently seeking ongoing training to expand and maintain knowledge base.
●Produced medical reports, correspondence and administrative material.
●Reviewed account information to confirm patient and insurance information is accurate and complete.
●Answered inquiries concerning progress of medical cases within limits of confidentiality laws.
●Determined correct ICD-10 and CPT codes for use in medical record.
●Translated medical jargon and abbreviations into expanded forms to promote accuracy of patient and health care facility records.
●Checked in patients to collect contact, medical and insurance information.
●Used EHR system to manage patient records, always maintaining patient confidentiality according to HIPAA standards.
●Reviewed medical records for accuracy and completion as required by insurance companies.
●Took dictation using shorthand, stenotype machine or headsets and transcribing machines.
●Transcribed dictation for variety of medical reports.
●Received and screened telephone calls and visitors.
●Reviewed patient records to code and abstract information on medical diagnosis and procedures.
●Monitored duration of basic lab results and screening procedures.
●Reviewed diagnostic and procedural terminology for consistency with acceptable medical nomenclature.
●Set up and maintained medical files and databases.
●Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
●Distinguished between homonyms and recognized inconsistencies and mistakes in medical terms.
●Reviewed diagnostic and procedural terminology for accuracy.
●Prepared and sent patient documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
●Reviewed and edited transcribed reports or dictated material for spelling, grammar and proper medical terminology.
●Performed data entry and data retrieval services for inclusion in medical records and transmission to physicians.
●Edited drafts originating from speech recognition software to eliminate errors and improve flow.
●Made corrections when needed to grammar, spelling and syntax.
●Identified mistakes in reports and checked with doctors to obtain correct information.
●Reconciled clinical notes, patient forms and health information for compliance with HIPAA rules.
●Followed clinicians throughout shift in high-volume, busy environments.
●Returned dictated reports for physician's review, signature and corrections and inclusion in patients' medical records.
Thumb Butte Medical Center - Medical Receptionist ( PRN )
December 2020-January 2023
●Processed patient payments and scanned identification and insurance cards.
●Took messages from patients and promptly relayed to appropriate staff.
●Called patients to confirm scheduled appointments and obtain additional details.
●Carried out daily tasks by professionally communicating with physicians, nursing staff, technicians and medical assistants.
●Informed patients of financial responsibilities prior to rendering services.
●Photocopied insurance cards, documented details and verified patient coverage for upcoming procedures or appointments.
●Straightened up waiting room to maintain neat and organized space.
●Answered multi-line phone system and directed callers to requested personnel and departments.
●Scheduled appointments, optimizing patient satisfaction, provider time and treatment room utilization.
●Maintained patient accounts by obtaining, recording and updating personal and financial information.
●Checked patients in and out for appointments and collected co-payments.
●Protected patients by observing strict HIPAA guidelines.
●Retrieved faxes and uploaded documents to patient charts to assist clinical staff.
●Conducted patient intake interviews to collect medical information and insurance details.
●Gathered, transcribed and typed medical information into charts.
●Managed office phone lines by checking voicemail, returning calls and directing messages to team members.
●Scheduled and followed up on patient appointments, collected and processed patient payments and maintained patient files.
●Compiled physical and digital documents, charts and reports.
●Trained new staff on office procedures, insurance processes and medical terminology.
●Entered insurance, demographics and health history into patient database.
●Delivered high-quality administrative and customer service to sustain patient and work flows.
●Greeted patients and visitors to answer questions or refer inquiries to appropriate personnel.
●Applied knowledge of medical terminology and insurance processes to support office administration productivity.
Family First Primary Care - Medical Assistant
January 2023- May 2023
●Collaborated with local pharmacies to resolve and clarify issues with patient medication.
●Relayed messages from patients to physicians about concerns, condition updates or refill requests to facilitate treatment.
●Contacted pharmacies to submit and refill patients' prescriptions.
●Maintained inventory, vaccination and product expiration logs to record updated documentation for tracking purposes.
●Responded to patient callbacks and phone-in prescription refill requests.
●Assisted with diagnostic testing by collecting and packaging biological specimens for internal and laboratory analysis.
●Labeled and completed lab requisitions using ICD and CPT coding.
●Prepared treatment rooms for patients by cleaning surfaces and restocking supplies.
●Educated patients about medications, procedures and physician's instructions.
●Cleaned and maintained medical equipment following procedures and standards.
●Interviewed and engaged patients to obtain medical history, chief complaints and vital signs.
●Participated in team meetings to improve workflows and contribute to improving patient population outcomes.
●Organized charts, documents and supplies to maintain team productivity.
●Measured vital signs and took medical histories to prepare patients for examination.
●Assessed, documented and monitored vital signs for patients within outpatient setting.
●Scheduled appointments for patients via phone and in person.
●Followed principles of asepsis and infection control to meet patient safety guidelines.
●Documented notes during patient visits.
●Incorporated outside records into charts and EHR.
●Secured patient information and maintained patient confidence by completing and safeguarding medical records.
●Administered rapid tests for COVID and strep to help clinical staff assess conditions.
Family First Primary Care - Medical Scribe
January 2023- May 2023
●Translated medical jargon and short-hand data into correct terminology.
●Informed doctor of urgent patient needs per nursing progress notes.
●Evaluated charts, documents and orders and made timely corrections.
●Documented and initiated tests, scan and other orders.
●Used medical record software every day and developed advanced skills.
●Transferred transcribed materials into electronic health records system.
●Input details about patient histories, physical examinations, medications and other information into physical or electronic charts.
●Demonstrated knowledge of terminology for multiple medical specialties, consistently seeking ongoing training to expand and maintain knowledge base.
●Produced medical reports, correspondence and administrative material.
●Reviewed account information to confirm patient and insurance information is accurate and complete.
●Answered inquiries concerning progress of medical cases within limits of confidentiality laws.
●Determined correct ICD-10 and CPT codes for use in medical record.
●Translated medical jargon and abbreviations into expanded forms to promote accuracy of patient and health care facility records.
●Checked in patients to collect contact, medical and insurance information.
●Used EHR system to manage patient records, always maintaining patient confidentiality according to HIPAA standards.
●Reviewed medical records for accuracy and completion as required by insurance companies.
●Took dictation using shorthand, stenotype machine or headsets and transcribing machines.
●Transcribed dictation for variety of medical reports.
●Received and screened telephone calls and visitors.
●Reviewed patient records to code and abstract information on medical diagnosis and procedures.
●Monitored duration of basic lab results and screening procedures.
●Reviewed diagnostic and procedural terminology for consistency with acceptable medical nomenclature.
●Set up and maintained medical files and databases.
●Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
●Distinguished between homonyms and recognized inconsistencies and mistakes in medical terms.
●Reviewed diagnostic and procedural terminology for accuracy.
●Prepared and sent patient documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
●Reviewed and edited transcribed reports or dictated material for spelling, grammar and proper medical terminology.
●Performed data entry and data retrieval services for inclusion in medical records and transmission to physicians.
●Edited drafts originating from speech recognition software to eliminate errors and improve flow.
●Made corrections when needed to grammar, spelling and syntax.
●Identified mistakes in reports and checked with doctors to obtain correct information.
●Reconciled clinical notes, patient forms and health information for compliance wit HIPAA rules.
●Followed clinicians throughout shift in high-volume, busy environments.
●Returned dictated reports for physician's review, signature and corrections and inclusion in patients' medical records.
Melinda M Martin MD:Obstetrician-Gynecologist - Medical Scribe / Medical Assistant
May 2023- Current
●Colposcopy - Endosee - Bladder Installation Procedures hands on with the provider.
●Collaborated with local pharmacies to resolve and clarify issues with patient medication.
●Relayed messages from patients to physicians about concerns, condition updates or refill requests to facilitate treatment.
●Contacted pharmacies to submit and refill patients' prescriptions.
●Maintained inventory, vaccination and product expiration logs to record updated documentation for tracking purposes.
●Responded to patient callbacks and phone-in prescription refill requests.
●Assisted with diagnostic testing by collecting and packaging biological specimens for internal and laboratory analysis.
●Labeled and completed lab requisitions using ICD and CPT coding.
●Prepared treatment rooms for patients by cleaning surfaces and restocking supplies.
●Educated patients about medications, procedures and physician's instructions.
●Cleaned and maintained medical equipment following procedures and standards.
●Interviewed and engaged patients to obtain medical history, chief complaints and vital signs.
●Participated in team meetings to improve workflows and contribute to improving patient population outcomes.
●Organized charts, documents and supplies to maintain team productivity.
●Measured vital signs and took medical histories to prepare patients for examination.
●Assessed, documented and monitored vital signs for patients within outpatient setting.
●Scheduled appointments for patients via phone and in person.
●Followed principles of asepsis and infection control to meet patient safety guidelines.
●Documented notes during patient visits.
●Incorporated outside records into charts and EHR.
●Secured patient information and maintained patient confidence by completing and safeguarding medical records.
●Administered rapid tests for COVID and strep to help clinical staff assess conditions.
●Produced medical reports, correspondence and administrative material.
●Reviewed account information to confirm patient and insurance information is accurate and complete.
●Answered inquiries concerning progress of medical cases within limits of confidentiality laws.
●Determined correct ICD-10 and CPT codes for use in medical record.
●Translated medical jargon and abbreviations into expanded forms to promote accuracy of patient and health care facility records.
●Checked in patients to collect contact, medical and insurance information.
●Used EHR system to manage patient records, always maintaining patient confidentiality according to HIPAA standards.
●Reviewed medical records for accuracy and completion as required by insurance companies.
●Took dictation using shorthand, stenotype machine or headsets and transcribing machines.
●Transcribed dictation for variety of medical reports.
●Received and screened telephone calls and visitors.
●Reviewed patient records to code and abstract information on medical diagnosis and procedures.
●Monitored duration of basic lab results and screening procedures.
●Reviewed diagnostic and procedural terminology for consistency with acceptable medical nomenclature.
●Set up and maintained medical files and databases.
●Demonstrated knowledge of HIPAA Privacy and Security Regulations by appropriately handling patient information.
●Distinguished between homonyms and recognized inconsistencies and mistakes in medical terms.
●Reviewed diagnostic and procedural terminology for accuracy.
●Prepared and sent patient documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.
●Reviewed and edited transcribed reports or dictated material for spelling, grammar and proper medical terminology.
●Performed data entry and data retrieval services for inclusion in medical records and transmission to physicians.
●Edited drafts originating from speech recognition software to eliminate errors and improve flow.
●Made corrections when needed to grammar, spelling and syntax.
●Identified mistakes in reports and checked with doctors to obtain correct information.
●Reconciled clinical notes, patient forms and health information for compliance wit HIPAA rules.
●Followed clinicians throughout shift in high-volume, busy environments.
●Returned dictated reports for physician's review, signature and corrections and inclusion in patients' medical records.
EDUCATION
Bradshaw Mountain High School -High School Diploma- August 2017 - May 2021
Yavapai Community College- 2021-Current
•Acquired Associates Degree
•Acquired Arizona General Education Certificate
•Currently in the process of finishing the Nursing a program
Contact this candidate