Clinical Documentation Assistant

Job Summary:
The Clinical Documentation Assistant plays a key role in ensuring the accuracy, completeness, and proper electronic filing of clinical documentation. This position supports quality assurance and compliance efforts by reviewing and managing clinical notes, reports, supervision logs, and other related documentation. The ideal candidate is detail-oriented, organized, and familiar with clinical documentation standards and electronic filing systems.

Key Responsibilities:

• Review clinical documentation including RBT notes, BCBA notes, monthly reports, and supervision logs to ensure accuracy and completeness.
• Verify that all documentation is consistent with clinical protocols and meets regulatory and organizational standards.
• Ensure that all documentation is accurately entered and locked in the electronic filing system.
• Maintain up-to-date records and perform routine audits to identify any discrepancies or missing information.
• Assist in managing data entry, record updates, and archiving procedures.
• Collaborate with clinical teams to address documentation errors or omissions.
• Generate reports to track documentation trends, compliance issues, and corrective actions.
• Work closely with the Quality Assurance team to implement improvements in documentation practices.
• Ensure all clinical documentation complies with HIPAA and other relevant privacy regulations.
• Maintain confidentiality and security of sensitive patient and organizational data.
• Serve as a liaison between clinical staff, supervisors, and administrative departments to resolve documentation issues.
• Provide support during audits and assist with the preparation of required documentation for regulatory reviews.

Qualifications:

• Previous experience in clinical documentation, medical records management, or a related administrative role.
• Familiarity with electronic health records (EHR) systems and data entry practices.
• Strong attention to detail and exceptional organizational skills.
• Excellent written and verbal communication skills.
• Knowledge of HIPAA guidelines and other relevant regulatory standards.

Skills:

• Proficiency in Microsoft Office Suite and EHR software.
• Ability to work independently and manage multiple priorities in a fast-paced environment.
• Strong analytical and problem-solving skills.
• Excellent time management skills and the ability to meet deadlines consistently.

This role is critical in maintaining the integrity of our clinical records and supporting overall quality improvement initiatives within the organization. If you are meticulous, organized, and committed to excellence in documentation, we encourage you to apply for the Clinical Documentation Assistant position.

Job Type: Full-time

Pay: From $18.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday
• Weekends as needed

Work Location: In person

Salary : $18