Clinical Documentation Specialist
Position Overview: Under the supervision of the Senior Clinical Supervisor, the Clinical Documentation Specialist is responsible to ensure that the quality of clinical documentation meets and exceeds all RCA, State, and Payor requirements within a variety of residential and outpatient levels of care. This position will be responsible for delivering qualitative analytics of care that is provided and reflected in the medical records to the Operations team. Analytics will be utilized to target both site and/or practitioner specific interventions thus driving positive patient outcomes. Key areas of focus are:
- Comprehensive multi-disciplinary assessment that drive individualized treatment planning
- High level of quality family interventions during treatment
- Engagement in 12 step education and programming
- Documentation reflects quality interventions; all problems identified are properly treated throughout stay
- Medical, psychiatric, and nursing interventions are clearly reflected in the charts and coordination of care with outside providers is occurring
- Ensure each patient has a comprehensive individualized aftercare plan that addresses MAT, comorbid medical and psychiatric needs, housing, family, community sober support and substance abuse follow up
- Daily review of charts
- Develop qualitative analytic reports on key metrics
- Monitoring of patient charts to ensure operational initiatives are adopted
- Proactive review of aftercare planning and coordination of care for discharging patients
- Validation that all sites are following operational requirements driven by payors, clinical updates, enhanced operational processes
- Understand RCA’s Quality Assurance expectations and proactively ensures documentation reflects such
- Work harmoniously with colleagues, supporting them as appropriate and balancing individual and team’s goals
- This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate.
Physical Demands: While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands to finger, handle or feel objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, or kneel. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Position Type/Expected Hours of Work: This is a full-time position. Days and hours of work are Monday through Friday, 8:30 a.m. to 5 p.m. Occasional evening and weekend work may be required as job duties demand.
Travel: Up to 25% travel is required which includes local, out-of-the-area, and overnight travel.