Pathology Transcriptionist

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Work Shift

Day (United States of America)

Overview

Under the supervision of department manager. Performs a variety of tasks in support of pathologists and other allied healthcare providers. Is accountable for ensuring accuracy and completeness of all documents, tests ordered and patient case reports which allows the pathologists to focus on patient care. The tasks include transcribing pathology reports as well as research and administrative documents. Responsibilities also include coordinating patient case correspondence materials for sending out for consultation. Responsibilities may include ordering tests and stains for cases answering phones and most often assisting the caller with patient report, adding stains to a current case, changing of patient demographics, or providing related follow through, participation in process improvement which includes data collection, coordinating case conference materials and maintain consultant calendar as appropriate. Required to follow work unit standard operating procedures along with reviewing and ensuring accuracy of those procedures. Routinely serves as a resource and mentor to others by training, educating and mentoring both new and existing members of the work unit and trouble shooting and resolving problems as appropriate.

Responsibilities

Core Responsibilities and Essential Functions

• Transcription/Work related to pathology reports both Gross and Microscopic
• Demographics of patients
• Gross transcription of dictation done by Pathologists Assistants or Pathologists depending upon type of specimen received.
• Microscopic transcription of dictation during the pathologist's review of slides for diagnosis.
• Notify pathologists of need for amendment/addendum of any case that needs further information in order for physician to make informed decisions. This information comes from outside reference labs, or consults with other site pathologists. Also, the reverse can occur with the pathologists notifying transcriptionists of need for amended/addendum based on additional info from within department consults. This requires previous transcription to be pulled and verified, and additional info be added and then physicians notified.
• Prepare CAP required tumor anatomical forms based on diagnosis of pathology report CPT codes.
• Work with pathologists when they are in need of further histories, additional current information, from WellStar or other hospitals. Must be aware of information that can be shared in order to obtain what is appropriate.
• Send out Cases for consult as appropriate per facility
• Document receipt of requests for slides/blocks.
• Request slides/blocks from Histology. Verify when received. Obtain pathology report.
• Discuss with pathologists the purpose of request in order for pathologist to make decision on which slides/blocks to send.
• Prepare package of blocks/slides/report and any comments from pathologists.
• Prepare invoice for billing of slides/blocks using department calculation as appropriate.
• Preparation of slides/block for Peer Review as appropriate per facility
• With knowledge of what are considered complex cases, select assortment of slides that reflect a diversified representation of complex cases (i.e., kidney resection, liver resection, brain tumor removal).
• Prepare for pathologist's review (depending upon who had the last peer review).
• Place selected slides in folder along with surgical protocol.
• Give to next pathologist in line for peer review.
• Professional Billing as appropriate per facility
• With professional billing, staff must have knowledge of documentation within pathology reports for special stains, and/or immuno histochemical stains. Billing in the professional genre is not billed out through the HIS; therefore, all charges are in the Pathology Information System. When errors are found and are not recognized until report has gone to CBO, staff interacts with Pathology Medical Billing Group in order to have correct billing processed by CBO.
• Technical Billing as appropriate per facility
• The technical billing component is billed out when the specimen is accessioned. If an error in technical billing requires assistance, the transcriptionist will research. This includes documenting how many parts to the specimen request, which specimen request the technical fee error belong with, and notifying Histology personnel to make changes in the technical fee charge.
• Physician Orders as appropriate per facility
• Physician orders that are received via fax, transcriptionist (with knowledge of appropriate pathology specimen availability for requested testing) staff will determine if tissue block contains enough tumor for testing. Also, if previous testing failed, are there alternative samples available for testing.
• Staff will work closely with representatives from reference labs to remain aware when new testing becomes available, after training by reference lab on test requirements and turnaround times, staff will order by completing requisition form for reference lab with technical information. Again, knowledge of appropriate specimen availability for testing is required.
• Preparation of slides/blocks for Tumor Board, Breast Tumor Board and occasionally County Tumor Boards as appropriate per facility
• Receive request from Tumor Board of request for slides/blocks. Prepare request for slides/blocks to be pulled from storage. If Histology unable to get pulled in timely manner, pull slides in order that remaining process can be continued.
• Prepare tray with slides selected by pathologists an also obtains pathology report.
• Check Tumor Board schedule/discuss with pathologists which slides/blocks have been pulled and then give this packet to the pathologist scheduled for Tumor Board.
• Legal Cases are a part of responsibilities of this department as appropriate per facility
• Staff must have knowledge and discretion to communicate effective with attorney's offices/staff and law enforcement individuals, communicate with Risk Management/Health Port staff obtaining validity and approval of requests, ability to understand and retrieve specific requested materials, complete and submit Pathology material inventory when requested, and with Notary Public when legal cases require notarization.
• Other Duties
• Answer phones for department
• Distribute mail
• Orders kits and supplies for reference lab send-outs
• Assists pathologist and histology techs as needed.
• Maintain pathology files.
• Provide pathologists with physician requests/information
• Required for All Jobs
• Performs other duties as assigned
• Complies with all WellStar Health System policies, standards of work, and code of conduct.
• Qualifications

Required Minimum Education *

• High school diploma Required or
• equivalent Required and
• Formal medical transcribing Preferred and
• Associate's Degree Preferred
• Required Minimum Experience
• Less than 1 year Six months transcription experience in medical setting with pathology experience Preferred and
• Knowledge of Pathology Information System billing, Tumor Conference preparation (all genres), Pathologist's Peer Review and CAP Anatomical Tumor Forms preferred as appropriate Preferred
• Required Minimum Skills
• Computer skills and medical terminology with pathology specialty preferred.
• Demonstrates initiative, proficiency and good judgment to optimize the use of other allied healthcare providers time.
• Must be high organized, efficient, and multifunctional with ability to work independently as well as in a team.
• Has excellent written and oral communication skills and experience in medical terminology and excellent customer service.
• High motivation and successful working independently and in a timely manner is required
• Required Minimum License(s) and Certification(s)

Additional Licenses and Certifications

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