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Clinical Documentation Associate

Full-time

RJING DENTAL CLINIC

A Clinical Documentation Associate is responsible for reviewing, managing, and ensuring the accuracy, completeness, and compliance of medical records and clinical documentation. They collaborate with healthcare providers to improve documentation quality, support coding and billing processes, and ensure adherence to regulatory standards.

Key Responsibilities:

  • Review and analyze clinical documentation for accuracy and completeness.
  • Work with healthcare providers to clarify documentation and ensure compliance with regulatory guidelines.
  • Assist in optimizing documentation for accurate coding and reimbursement.
  • Maintain patient records and ensure confidentiality in accordance with HIPAA and other regulations.
  • Identify gaps in documentation and suggest improvements.
  • Stay updated with healthcare documentation standards and compliance requirements.
  • Education: Bachelor's degree in healthcare administration, nursing, medical coding, or a related field (preferred).
  • Experience: Prior experience in clinical documentation, medical coding, or healthcare administration is a plus.
  • Knowledge: Understanding of medical terminology, ICD-10, CPT coding, and regulatory guidelines (e.g., HIPAA, CMS).
  • Skills: Strong attention to detail, analytical thinking, communication skills, and proficiency in EHR/EMR systems.
  • Would you like me to tailor this for a specific industry or company?
Vacancy posted 21 days ago
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