RN Clinical Documentation Specialist

***This is an in-person position***

POSITION BENEFITS:

• Competitive Pay

• Excellent Hours- Work Monday-Friday from 8am-4pm

• Small family centered agency that encourages a work -life balance.

• Paid Time Off- Up to 5 weeks a year!

• Comprehensive Health Insurance Benefits (medical, dental, vision)

• Employer paid Life and Disability insurance.

• 401(k) Retirement Savings Plan with Company Matching Contributions

• Mileage Reimbursement

• Free Training

• Employee referral bonuses

Conduct clinical documentation review for timeliness and accuracy and make recommendations as appropriate. Ensure compliance with documentation requirements set forth by agency policy, accrediting bodies, regulatory entities, and payer requirements. Facilitate the improvement in the overall quality, completeness and compliance of clinical documentation in the medical record.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Reviews and approves all Hospice and Private Duty assessments and creates Plan of Care.
• Reviews and creates all Home Care Plans of Cares, to be compliant with CMS standards. 
• Facilitates clarification of clinical documentation to ensure complete and compliant documentation that reflects the level of service rendered and medical necessity.
• Demonstrates knowledge of documentation requirements and guidelines.
• Performs a thorough review of the Plan of Care to ensure compliance and completeness. 
• Identifies trends and opportunities to improve the accuracy of medical record documentation.
• Establishes and maintains a system to track and analyze outcomes of documentation improvement program.
• Facilitates performance improvement activities related to the operational processes for the Clinical Documentation Performance Improvement Program (QAPI) and participates in the Fall Committee. 
• Provides education to staff on QAPI and agency Performance Improvement Plan (PIP) goals. 
• Tracks documentation issues by employees and communicates with clinical management staff regarding employees with repeated documentation issues.
• Keeps informed regarding documentation requirements by accrediting bodies, regulatory entities, payer requirements, and agency policy. serves as a resource to visiting staff. 
• Performs patient visits as requested by the Director of Home Health & Hospice or the CEO. 
• Other duties as assigned. 

EDUCATION AND EXPERIENCE

• Associates Degree of Science in Nursing.
• Current licensure as a Registered Nurse in the State of New Hampshire.
• Minimum of 1-2 years’ experience in Home Care required, COQS or obtained within 1 year, ICD-10-CM and CPT coding practices preferred.
• Experience in data analysis, infection control practices and/or quality improvement processes.

REQUIRED SKILLS AND ABILITIES

• Ability to travel required. Travel throughout central New Hampshire to observe Home Health care service and other job-related activities is required.
• Current drivers’ license required.
• Proof of automobile insurance required. 
• Ability to pass a motor vehicle background screening.

PHYSICAL DEMANDS/WORK ENVIRONMENT

• Job requires some physical activities including but not limited to, sitting or standing for extended periods of time, typing, reaching, standing, walking, kneeling, lifting, fingering, grasping, feeling, talking and hearing. 
• Job requires use of general office equipment including phones, copiers and computer equipment.
• Job requires light physical work including the ability to exert up to 20 lbs. of force occasionally, 10 lbs. regularly.
• Job requires visual acuity including the ability to see at or within arm’s reach as well as to operate a motor vehicle.
• Job is subject to inside environmental conditions, low noise level.