POSITION OVERVIEW:
Under the supervision of the VP of Quality, the Clinical Documentation Improvement Specialist is responsible to ensure that the quality of clinical documentation meets and exceeds all RCA, State, and Payer 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 ARES OF FOCUS TO INCLUDE:
Comprehensive, multi-disciplinary assessments that drive individualized treatment planning High-quality family interventions during treatmentDocumentation that reflects clinical quality, ensuring that all identified problems are addressed and treated throughout the patient’s stay Medical, psychiatric, and nursing interventions are clearly documented coordination of care among internal and external providers Service delivery requirements are documented including individual and group therapy, and psychoeducation groups Ensuring that each patient has a comprehensive, individualized aftercare plan that addresses medication-assisted treatment (MAT), comorbid medical and psychiatric needs, housing, family dynamics, community sober support, and substance abuse follow-up
KEY RESPONSIBILITIES:
Daily audit of patient medical records to ensure that the organization is complying with applicable local, state, and federal regulations as well as internal organization expectations Daily review of Clinical Census and Scheduled Discharge Reports Develop ASAM qualitative analytic to reports on key metrics Monitoring of patient charts to ensure operational initiatives are adopted 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 Ensures compliance with regulations and controls by examining and analyzing records, reports, operating practices, and documentation, recommending opportunities to strengthen the internal control structure Review of Clinical Census and Discharge Calendar Reports Duties, responsibilities and activities may change at any time with or without notice
SKILLS AND EDUCATION:
Bachelor’s degree required, Master’s Degree or higher in Psychology, Counseling, Social Services, or related field Preferred. At least two years of experience in behavioral health/substance use disorder treatment required Strong working knowledge of clinical documentation expectations Strong working knowledge of ASAM Exceptional verbal and written communication skills Experience creating analytics dashboards Willingness to be flexible in adjusting to new and changing situations Proficiency in Microsoft Office products Meets productivity standards; completes work in timely manner; strives to increase productivity; works quickly Self-starter and self-motivated; undertakes self-development activities; seeks increased responsibilities; takes independent actions and calculated risks; looks for and takes advantage of opportunities; asks for and offers help when needed Ability to work independently and as part of a team Interpret regulations, guidelines, and compliance requirements and communicate them to other team members and functionalities/departments within the organization while demonstrating a high ability to make appropriate decisions Excellent organizational skills required
WORK ENVIRONMENT:
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.
TRAVEL:
Up to 25% travel is required, which includes local, out-of-the-area, and overnight travel.
Job Type: Full-time
Work Location: Remote