Clinical Documentation Review Team Lead

Pennant Services

1d

About The Position

The Clinical Documentation Review Team Lead plays a critical role in ensuring the accuracy, consistency, and defensibility of clinical documentation reviews companywide. This position maintains full Clinical Documentation Review Specialist responsibilities while serving as the clinical and operational lead for the documentation review team. The Team Lead provides real-time guidance, quality oversight, mentorship, and workflow support to ensure review alignment with regulatory requirements and internal standards. This role promotes accountability, collaboration, and continuous improvement across the team while continuing to complete assigned documentation reviews. The ideal candidate has strong clinical knowledge of both Home Health and Hospice, excellent communication skills, regulatory expertise, and demonstrated ability to guide peers toward consistent, high-quality documentation practices.

Requirements

• Registered Nurse or related licensure highly preferred.
• Significant experience and knowledge of the Home Health and/or Hospice environment, typically gained by five or more years of industry-related experience.
• Strong knowledge of Medicare and Medicaid regulations.
• Demonstrated ability to interpret and apply CMS Conditions of Participation and Conditions of Payment.
• Strong sense of autonomy and confidence when working independently while also functioning effectively as a team leader.
• Demonstrated ability to mentor and guide peers while maintaining collaborative relationships.
• Demonstrates initiative in researching and resolving issues.
• Able to discern areas in need of continued improvement.
• Detail and deadline oriented with the ability to prioritize and multitask.
• Able to adapt to a fast-paced environment and learn and retain new or evolving information and procedures.
• Able to collaborate with physicians and healthcare providers to clarify clinical documentation and obtain additional information when necessary.
• Flexible and responsive to changing business needs.
• Proficient in Microsoft Office Suite (Excel, Word, PowerPoint, Smartsheet).
• Experience with HCHB required.

Nice To Haves

• Prior documentation review, audit, or compliance experience preferred.

Responsibilities

• Conduct detailed home health and hospice pre-billing reviews to support Portfolio partners and their agencies.
• Identify discrepancies, missing information, and opportunities for documentation improvement.
• Utilize information gathered to provide education and facilitate alterations to the HCHB documentation, and process improvements to prevent recurrence.
• Direct agencies to use documentation data outcomes for QA improvements.
• Ensure documentation accurately reflects the patient’s clinical status and the care provided.
• Set up meetings with clinical leaders to provide education, highlight findings, and make documentation recommendations.
• Stay current with practices in both home health and hospice fields and suggest educational and resource materials which would be beneficial to the staff.
• Recommend new approaches to on-going continued improvements to policies, procedures, and documentation.
• Identify trending issues and share them with the team and the clinical leaders.
• Stay up to date with all federal, state, and local regulations, as well as organizational policies and procedures to ensure compliance.
• Work within and be comfortable with HCHB, PDF-Xchange, Excel, and Smartsheet.
• Consistently promote CAPLICO
• Serve as the first point of escalation for documentation review questions.
• Provide real-time guidance on documentation standards, interpretation, and expectations.
• Reinforce consistency in review methodology across all reviewers.
• Hold team alignment meetings to discuss review findings and ensure standardization.
• Support onboarding and mentoring of new documentation reviewers.
• Identify training gaps and recommend targeted education.
• Monitor review quality and provide constructive feedback to promote defensible documentation practices.
• Track common documentation deficiencies and trends and share with leadership.
• Escalate systemic issues to the Director with recommended solutions.
• Assist with workload balance and prioritization when needed.
• Monitor turnaround times and flag potential deadline risks.
• Reinforce accountability while maintaining a positive and collaborative team culture.

Benefits

• We are committed to providing a competitive Total Rewards Package that meets our employees’ needs. From a choice of medical, dental, and vision plans to retirement savings opportunities through a 401(k) plan with company match and various other benefits, we offer a comprehensive benefits package.
• We believe in great work, and we celebrate our employees' efforts and accomplishments both locally and companywide, recognizing people daily through our Moments of Truth Program.
• In addition to recognition, we believe in supporting our employees' professional growth and development. We provide employees a wide range of free e-courses through our Learning Management System as well as training sessions and seminars.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed