Clinical Documentation Specialist - (US Based Client)

Salary Budget : Up until 65K Php

Work Setup: On Site for 2 months, transition to WFH over time w/ performance

Work Schedule : 8am to 5pm , Eastern Timezone

Job Description

The Clinical Documentation Specialist supports healthcare providers by reviewing and improving the accuracy, completeness, and quality of clinical documentation. This role ensures patient records reflect the appropriate level of care and support correct coding, compliance, and reimbursement processes.

Key Responsibilities:

• Review clinical notes, medical charts, and coding documentation for accuracy and completeness.
• Collaborate with physicians, nurses, and coders to clarify or improve clinical documentation.
• Identify gaps or inconsistencies in patient records and ensure compliance with U.S. regulatory standards.
• Maintain patient confidentiality and follow HIPAA and company-specific privacy guidelines.
• Generate reports and documentation summaries as required.
• Participate in training and quality improvement initiatives.

Duties and Responsibilities

• Ensure accurate and complete documentation for patient care.
• Support coding and billing compliance.
• Communicate effectively with healthcare professionals to resolve documentation issues.
• Maintain high standards of confidentiality and professionalism.
• Contribute to continuous improvement initiatives and training programs.

Qualifications

• Must hold at least a bachelor’s degree.
• Minimum 5+ years of clinical experience in U.S. healthcare, with pharmacy experience required.
• Software Skills: Proficient in Excel, QuickBooks, MS Office; familiarity with NexGen EHR (preferred).
• Hard Skills: Clinical documentation, coding knowledge (ICD-10, CPT), and compliance expertise.
• Soft Skills: Strong communication and interpersonal skills.