Clinical Documentation Assistant

5 days ago

Taguig, National Capital Region, Philippines Creathink Solutions Full time ₱1,200,000 - ₱2,400,000 per year

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

  1. Proficient in documenting clinical treatment plans, group notes, ASAMs, intake

    assessments, and one-on-one notes
  2. Accurately document patient encounters, histories, clinical findings, discharge

    summary, during or after consultations/confinement
  3. Enter information, lab results, and other relevant data into electronic health

    records (EHR) system patients.
  4. Regularly update patient records with new information, including diagnoses,

    treatments, and follow-up plans.
  5. Assist with the assignment of appropriate medical codes based on

    documented information.
  6. Review documentation for completeness, accuracy, and consistency.
  7. Ensure documentation adheres to healthcare regulations and standards (e.g.,

    HIPAA).
  8. Assist with internal and external audits by providing necessary documentation

    and information.
  9. Provide reminders for follow-up care, medication renewals, and other clinical

    tasks.
  10. 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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