Clinical Documentation Specialist

Responsible for review of clinical documentation to ensure documentation in the visit note supports a skill was provided and services are medically necessary. Must be able to communicate effectively, while influencing and motivating company personnel who do not directly report to the Documentation Specialist.

• Consistently engages with clinicians to improve accuracy of documentation, ensures that documentation supports a skill was provided and supports medical necessity
• Reviews clinical notes as assigned and scores notes in scoring tool.
• Meets or exceeds productivity expectations
• Consistently produces accurate and reliable reviews, maintaining high standards of quality
• Effective verbal and written communication skills.
• Identified educational trends and discusses with Clinical Director and Director of Quality and Clinical Informatics to further train/educate staff and improve documentation. Reports to supervisor and operational leadership any continued lack of improvement or engagement from clinicians.
• Assists with reviews during state audits as needed
• Other duties as assigned.

Job Qualifications:

Licensed Practical/Vocational Nurse, Licensed Registered Nurse, Licensed Physical Therapist, Licensed Physical Therapist Assistant, Licensed Occupational Therapist, Certified Occupational Assistant, Licensed Speech Language Pathologist, or Social Worker

1 year of home health/hospice experience required.