This is a work from home set up.

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 tasksDocument 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.