Documentation Specialist

United States·ClaytonFull-Timemid

Healthcare Non-ClinicalClinical Documentation Specialist

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Requirements Summary

Specific Qualifications: Make observations and document consumer treatment interventions,

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Healthcare Non-ClinicalClinical Documentation Specialist

Job Description for an Associate Professional Documentation SpecialistEducational Requirements:Specific Qualifications:
- Make observations and document consumer treatment interventions, behavior and progress
- Submit notes daily on caseload
- Assist with overseeing units on the floor during staff absence
- Assist with the development, implementation, monitoring and revision of the Person
Centered Plan (PCP) as it relates to the needs of the individual, as needed
- Consult with identified professionals, family members and others, include their input in
the Person-Centered Planning process, inform all involved stakeholders, monitor the
- Works closely with Quality Assurance & Improvement Coordinator (QA/QI) and Program Director to improve note writing/workflow processes
Must be a compassionate individual willing to be additionally trained to interact with the severe and persistently mentally ill. Fast-paced, high tech, consumer-focused, in an innovative clinical environment, constantly evaluating and improving processes; creativity encouraged. Knowledge, Skills and Abilities: Documentation – Knowledge of NC Medicaid documentation requirements Ability to handle crisis/emergency situations, and to utilize conflict resolution skills Ability to work with QA/QI Coordinator, Program Director and/or QP to develop and follow an individual supervision plan Monday – Friday 8:30am – 4:00pm
Wages: $17.00-$20.00
Work Hours:
Knowledge of basic computer and applications to include Microsoft Word
Knowledge of Client Rights
Knowledge of Community Based Resources
The work environment is:
Employment Requirement:
status of the consumer relationships in relation to treatment goals.
An individual highly motivated with strong communication skills-- a must have (verbal and written) these skills are critical for overall success as a Documentation Specialist. Complete weekly progress notes guided by consumer’s identified goals. Must be able to strategize; to meet documentation deadlines.
Graduate of a college or university with a bachelor's degree in a human service field or at least two years pre or post-bachelor's degree accumulated mh/dd/ experience with the population served (this position will work with the severe and persistently mentally ill), Supervision shall be provided by a qualified professional with the population served until the individual meets two years of experience. The supervisor and the employee shall develop an individualized supervision plan upon hiring. The parties shall review the plan annually.
The primary job function of the Associate Professional (AP) Documentation Specialist is to complete weekly progress notes. As needed, the Documentation Specialist will assess member needs, abilities and interests, plan, conduct and facilitate involvement in therapeutic vocational, recreation and community integration programs/units and organize special events.