Careers

Clinical Documentation Assistant

Work From Home

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:

CTS Application Form & English Proficiency Test

Application Form

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