Clinical Documentation Specialist

Hammerjack Pty Ltd; Manila; On-site; PHP 500,000 - 700,000; Full time

Job summary

Hammerjack Pty Ltd is seeking a Clinical Documentation Specialist in Manila, Philippines. This role involves overseeing medical recordkeeping practices and ensuring compliance with federal documentation laws. The candidate will need to apply knowledge of medical terminology and maintain accurate patient records.

Candidates must hold a Bachelor of Science in Nursing and be a licensed Registered Nurse, with preferred experience in medical coding and healthcare environments. Join a team dedicated to high-quality clinical documentation!

Qualifications

• Experience in revenue cycle and medical coding is preferred.
• Knowledge of ICD-10 diagnosis coding guidelines is necessary.
• Experience in clinical or hospital settings is a plus.

Responsibilities

• Evaluate clinical documents using medical knowledge.
• Update medical records and verify patient information.
• Prepare clinical reports for healthcare professionals.
• Ensure compliance with federal laws and HIPAA.

Skills

Knowledge of medical terminology

Attention to detail

Critical thinking

Teamwork

Education

Bachelor of Science in Nursing

Licensed Registered Nurse

Job description

Job Summary

Clinical Documentation Specialist is responsible to oversee the facility's medical recordkeeping practices. In this role, Clinical Documentation Specialist is responsible for ensuring that clinical documentation complies with federal laws, provide feedback in medical recordkeeping practices, and analyzing medical information.

Essential Duties and Responsibilities

1. Applying knowledge of medical terminology and procedures to evaluate clinical documents.
2. Collecting medical information from healthcare providers and updating medical records.
3. Verifying the accuracy of patient medical information and obtaining missing information.
4. Monitoring diagnoses, treatments, and follow-up entries in medical records.
5. Interpreting and preparing clinical reports for healthcare professionals and public health officials.
6. Ensuring that the content and storage of medical documents comply with federal laws.
7. Keeping abreast of advancements in the field of clinical documentation and changes in regulations.
8. Keeping updated to official coding guidelines for diagnosis and be able to follow the facility specific guidelines and instructions.
9. Maintains confidentiality of patient records at all times.
10. Observes HIPAA compliance.
11. Perform as a team player.
12. Use logic, critical thinking and reasoning to identify the strengths and weaknesses of alternative solutions to problems.
13. Understand the effects of new information for both current and future problem-solving and decision-making.
14. High attention to detail
15. Attendance in accordance with company HR and department policies
16. Other tasks/functions that may be assigned by the company as per business requirement; these may change from time to time to reflect the changing requirement of your position and our business.

Education or Equivalency

1. Bachelor of Science in Nursing graduate
2. Licensed Registered Nurse
3. Preferably with work experience in

• Revenue Cycle (medical coding) experience.
• Knowledge of medical terminologies, ICD-10 diagnosis coding guidelines, procedures.
• Clinical or Hospital setting

Certification or Licensure

• Certification is dependent on client requirement.
• AAPC Coding Certification: CPC, COC, CIC
• AHIMA Coding Certification: CCA, CCS-P, CCS

Working Conditions and Physical Requirements

1. Pleasant work environment.
2. Job requires sitting and working at a computer for extended period of time; 8 hours minimum.