Clinical Documentation Improvement Specialist

Recovery Centers Of America - King of Prussia, PA

Full-time

King of Prussia, PA

Hospitals

About the position

The Clinical Documentation Improvement Specialist plays a crucial role in ensuring the quality of clinical documentation across various levels of care, meeting and exceeding regulatory requirements. This position involves delivering qualitative analytics of care reflected in medical records, which will be utilized to target specific interventions aimed at improving patient outcomes. The specialist will focus on comprehensive assessments, high-quality family interventions, and ensuring that documentation accurately reflects clinical quality throughout the patient's treatment journey.

Responsibilities

• Daily audit of patient medical records to ensure compliance with local, state, and federal regulations as well as internal expectations.
• Daily review of Clinical Census and Scheduled Discharge Reports.
• Develop ASAM qualitative analytics to report on key metrics.
• Monitor patient charts to ensure operational initiatives are adopted.
• Validate that all sites are following operational requirements driven by payors and clinical updates.
• Understand RCA's Quality Assurance expectations and ensure documentation reflects these standards.
• Work harmoniously with colleagues, balancing individual and team goals.
• Ensure compliance with regulations by examining and analyzing records and documentation, recommending improvements.
• Review Clinical Census and Discharge Calendar Reports.

Requirements

• 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.
• Proficiency in Microsoft Office products.
• Ability to work independently and as part of a team.
• Excellent organizational skills.

Nice-to-haves

• Willingness to be flexible in adjusting to new and changing situations.
• Self-starter and self-motivated; seeks increased responsibilities and takes independent actions.