Job Overview:
We are seeking a detail-oriented and efficient Clinical Documentation Assistant to join our client’s team. This role involves providing remote support to a company in the healthcare industry by managing and improving the documentation of patient records. The ideal candidate will have a strong understanding of medical terminology, excellent organizational skills, and a commitment to maintaining accurate and complete medical records.
Responsibilities:
-
Proficient in documenting clinical treatment plans, group notes, ASAMs, intake assessments, and one-on-one notes
-
Accurately document patient encounters, histories, clinical findings, discharge summary, during or after consultations/confinement
-
Enter information, lab results, and other relevant data into electronic health records (EHR) system patients.
-
Regularly update patient records with new information, including diagnoses, treatments, and follow-up plans.
-
Assist with the assignment of appropriate medical codes based on documented information.
-
Review documentation for completeness, accuracy, and consistency.
-
Ensure documentation adheres to healthcare regulations and standards (e.g., HIPAA).
-
Assist with internal and external audits by providing the necessary documentation and information.
-
Provide reminders for follow-up care, medication renewals, and other clinical tasks.
-
Document patient follow-up care instructions and ensure effective communication with the patient.
Qualifications:
-
At least college-level
-
Has strong attention to details
-
Should be teachable, punctual, and efficient
-
Understanding of medical terminology, clinical procedures, and healthcare documentation standards.
-
Ability to accurately and thoroughly document patient information.
-
Familiarity with Electronic Health Records (EHR) systems, medical coding, and other relevant software.
-
Strong written and verbal communication skills to interact effectively.
-
Adherence to patient confidentiality and data protection regulations.
-
Previous experience in a medical office, hospital, or similar healthcare setting is preferred.
- Knowledge in the MS Office (Excel, Word, etc.) or Google Workspace (G Suite) and agility in learning new internal software and systems.
Minimum Requirements:
- i5 10th Gen or equivalent, 8GB RAM, 2GB Video Card or Integrated Graphics Card, Windows 10 or macOS (no Netbooks or Chromebooks), Headset with noise cancellation feature
- Main Internet should be minimum of 20MBPs, wired only
- An Antivirus Software should be installed, activated and updated
- Backup Internet
- Quiet Workplace
If you are qualified or you know someone who is interested, please complete the Application Form and the English Proficiency Test below:
