
Clinical Documentation Assistant
2 days ago
This is a work from home set up.
Per hour rate: 115 plus Internet Allowance 2,000
Part time - Project Based
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.
Key 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 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
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.
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