Clinical Documentation Specialist

Description


LOCATION:

Main office in Randolph, Massachusetts with satellite locations in Medford and Dorchester in Massachusetts. Administrative staff can be designated to work at any of our office sites within the regions we cover based on positions that are available and travel will be required at times.

JOB SUMMARY:

The Clinical Documentation Specialist is responsible for optimizing internal controls. The Documentation Specialist will review and edit Medicare Managed clinical documentation to ensure compliance based on program specification for services, coding accuracy, and revenue authorization. In addition to optimizing efficiencies and ensuring positive patient outcomes by achieving metric goals via auditing standards.

POSITION RESPONSIBILITIES AND TASKS:

  • Main contact to audit streamline patients into outpatient programs. Assists with completing review and with documentation completion and authorizations
  • Creates weekly reports, maintains and tracks intake documentation and authorizations to meet medical necessity and services specifications
  • Properly tracks and follows up with direct care staff documentation
  • Distributes all finalized documentation to appropriate staff
  • Provides clinically-based concurrent review of outpatient medical records to assess and procure accurate and complete documentation of the patients’ diagnoses and procedures
  • Coordinates patient’s health records and assists in treatment coordination
  • Assists with maintaining and establishing standards for best practices including intake policies and procedures, assessments, treatment plans, discharge plans, trains employee on best practices and quality assurance measure
  • Coordinates with Healthcare Auditing Coordinator
  • Coordinates patient’s health records and assists in treatment coordination
  • Audits records and trains staff on compliance measures and creates training materials
  • Assists in training and development of new and ongoing staff
  • Ensures documentation accurately reflects the quality of care, the severity of illness and risk of mortality to support correct coding, reimbursement, and quality initiatives
  • Works in collaboration with all departments to ensure compliance with medical necessity and services specifications
  • Follows Operating Principles of LAMOUR Clinic when completing all tasks
  • Adheres to the system and department compliance policies, and any applicable laws and regulations. Performs other duties as assigned
  • Keep Program Director informed of potential and/or actual problems identified during the review process, concurrent progress and operation of the program
  • Perform initial case reviews, follow up reviews and queries based on program standards
  • Has a strong working knowledge of patient safety indicators, healthcare regulations, reimbursement and documentation requirements
  • Maintains professional competency by keeping abreast of new changes within the industry including coding clinics, advancements in medical treatment, and guidelines

 KEY SKILLS & BEHAVIOR:

  • Experience working in a fast-paced environment
  • Good verbal, written and interpersonal communication skills
  • Knowledge of document control policies and practices
  • Ability to learn new software/systems quickly
  • Excellent computer skills
  • Highly adaptable and detail orientated
  • Work well within a team
  • Have an outstanding work ethic

SALARY & BENEFITS:

  • $20 – $25 per hour depending on experience
  • Paid Time Off (PTO)
  • Paid holidays
  • Medical & Dental
  • Education benefits towards master’s degree in counseling, Psychology, Social Work or Education with a concentration in concentration in Applied Behavior Analyst
  • Flexible Schedule but must be able to work in the late afternoons and evening until 8:15pm and some weekends

Location: Randolph, MA

Job Type: Full-time

Program: Documentation

Department: Quality Management

Age group:

Qualifications


QUALIFICATION REQUIRED AND EXPERIENCE:

  • Social Work Master’s degree or equivalent clinical education
  • Experience as an archivist or documentation specialist, preferably with intake assessments, treatment planning, obtaining authorizations for billing within healthcare environment, with 1 years of experience BS or a BA, or pursuing of experience with MSW or MA OR be willing to be trained
  • Current clinical degree or license in Massachusetts preferred
  • Thorough knowledge of medical necessity and services specifications behavioral health outpatient programs
  • Strong computer skills and ability to learn various software packages
  • Detail-oriented skills with the ability to organize and prioritize workload
  • Previously demonstrated ability to achieve results by holding self-accountable
  • Strong written, verbal and electronic communications skills.
  • Ability to work with and positively influence a variety of personalities and diverse work styles

 Must be Culturally and Linguistically competent; Bilingual a plus: Haitian Creole, Portuguese Creole, Spanish, Vietnamese, Chinese or Cambodian

 


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