Muntinlupa - Clinical Documentation Assistant

This is a work from home set up.

Job Overview: We are seeking a detail-oriented and efficient Clinical Documentation Assistant to

accurate and complete medical records.

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

1. Accurately document patient encounters, histories, clinical findings, discharge

1. Enter information, lab results, and other relevant data into electronic health

1. Regularly update patient records with new information, including diagnoses,

1. Assist with the assignment of appropriate medical codes based on

1. Review documentation for completeness, accuracy, and consistency.
2. Ensure documentation adheres to healthcare regulations and standards (e.g.,

1. Assist with internal and external audits by providing necessary documentation

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

1. 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.