Clinical Documentation Compliance Specialist

AltaPointe Health • Mobile, AL

118d

About The Position

The position involves conducting monthly billing supervision audits on all service providers delivering Outpatient and/or Residential Mental Health (MH) and Addiction Recovery Services (ARS). The role requires effective communication with employees and their clinical or administrative supervisors when necessary. The billing audit will include a thorough review of notes and assessments written by service providers to ensure that the note headings match the content and the service codes being billed. Additionally, it is essential that treatment plans are attached to the notes and accurately reflect the work being done in the sessions. Regular audits of clinical documentation will be performed to ensure compliance with federal, state, and payer-specific regulations, identifying documentation deficiencies and providing corrective action recommendations to providers. The role also includes designing and facilitating training programs for licensed providers and clinical staff, focusing on accurate clinical documentation, billing compliance, and coding best practices. Supportive resources such as documentation tools, templates, and tip sheets will be developed to promote consistent and compliant charting and coding. The position requires providing both one-on-one and group education sessions, including onboarding and ongoing continuing education. Monitoring and analyzing changes in regulatory requirements and coding policies is crucial, as is effectively collaborating and communicating relevant updates to key stakeholders. The role supports the preparation and execution of internal and external audits, including the development and implementation of corrective action plans. Maintaining compliance policies and procedures related to clinical documentation and billing practices is also a key responsibility. The individual must demonstrate courteousness and respect towards patients, visitors, and co-workers, ensuring privacy and confidentiality. They should be pleasant and cooperative, sensitive to the needs and expectations of providers and patients alike. Administrative duties include participating in performance improvement activities, attending AH committees as requested, completing assigned tasks timely, following AH policies and procedures, and maintaining current licenses and requirements for renewals, including attending regular workshops and in-services.

Requirements

• Master’s level degree or equivalent in a mental health discipline or Independent License such as an LCSW, LPCC, MSN.
• At least 2 years’ experience in the mental health field.
• Knowledge in adult and child/adolescent behavioral healthcare and intellectual disabilities to be attained within 6 months of employment.
• Knowledge of clinical documentation requirements for inpatient, residential, and outpatient programs.
• General knowledge of billing standards and practices.
• Knowledge of monitoring agencies standards (JC, DMH, CMS, Medicaid, Medicare, HRSA, ABON, etc.).
• Knowledge and utilization of tools to monitor clinical compliance.
• Knowledge of the organization’s policy and procedures.
• Knowledge of EHR systems and documentation.

Responsibilities

• Conduct monthly billing supervision audits on all service providers providing Outpatient and/or Residential MH and ARS Services.
• Communicate with employees and/or the employee's clinical and/or administrative supervisor when appropriate.
• Review notes and assessments written by service providers to confirm that note headings match the content and the service code being billed.
• Ensure treatment plans are attached to the notes and reflect what is being worked on in the session.
• Perform regular audits of clinical documentation to ensure compliance with federal, state, and payer-specific regulations.
• Identify documentation deficiencies and provide corrective action recommendations to providers.
• Design and facilitate training programs for licensed providers and clinical staff focused on accurate clinical documentation, billing compliance, and coding best practices.
• Develop supportive resources such as documentation tools, templates, and tip sheets to promote consistent and compliant charting and coding.
• Provide 1:1 and group education sessions, including onboarding and ongoing continuing education.
• Monitor and analyze changes in regulatory requirements and coding policies.
• Collaborate and communicate relevant updates to key stakeholders.
• Support the preparation and execution of internal and external audits, including the development and implementation of corrective action plans.
• Assist in the creation and maintenance of compliance policies and procedures related to clinical documentation and billing practices.
• Participate in Performance Improvement activities.
• Participate in AH committees as requested.
• Complete assigned tasks in a timely manner.
• Follow AH policies and procedures.
• Maintain current license and requirements for renewals (i.e. CEUs), if applicable, and attend regular workshops and in-services.

What This Job Offers

• Education Level: Master's degree
• Number of Employees: 1,001-5,000 employees