Clinical Documentation Specialist

Main Line Health • Radnor, PA

12d • Onsite

About The Position

The Clinical Documentation Specialist oversees and evaluates home health services to ensure optimal clinical outcomes, financial performance, and regulatory compliance. The Clinical Documentation Specialist reviews all clinical assessment (OASIS and HOPE) documentation and assesses appropriate visit utilization patterns based on the care needs of the client and the reimbursement to be received by the agency for providing this care. The Clinical Documentation Specialist makes these decisions by reviewing the gross profit margin of each home health client and the ability of the client/caregiver to support care in the home. This decision is reached in collaboration with the payor as needed. The Clinical Documentation Specialist assigns accurate and compliant ICD‑10-CM diagnosis codes for all home health and hospice patients based on clinical documentation, assessment findings, and regulatory guidelines. The Clinical Documentation Specialist oversees the progress of the client during the home health episode of care and monitors care events that may trigger a change in care needs. For assigned cases, the Clinical Documentation Specialist reviews and signs all plan of care orders for home health and hospice clients (Medicare form-485 orders), CTI orders and service orders going to physicians. The Clinical Documentation Specialist manages an average active caseload of 125-150 clients (approximately 1800 clients annually) and monitors the activity of 300 clinical staff. On an annual basis, this individual directly influences revenue of over 2 million dollars.

Requirements

• Three to Five years of clinical experience.
• Basic computer skills required.
• Knowledge of Medicare regulations pertaining to Home Health.
• Graduation from an accredited School of Nursing required.
• Associates Degree required.
• Current licensure in the Commonwealth of Pennsylvania as a Registered Nurse

Nice To Haves

• Two years of home care experience preferred.
• Knowledge of home health information system is a plus.
• Expertise in Home Health Coding preferred.
• Bachelor's degree preferred.
• Home Care Coding Specialist - Diagnosis (HCS-D) Certification and Home Care Coding Specialist - OASIS (HCS-O) Certification preferred or will be obtained within 2 years of accepting the position.

Responsibilities

• Oversees and evaluates home health services to ensure optimal clinical outcomes, financial performance, and regulatory compliance.
• Reviews all clinical assessment (OASIS and HOPE) documentation and assesses appropriate visit utilization patterns based on the care needs of the client and the reimbursement to be received by the agency for providing this care.
• Reviews the gross profit margin of each home health client and the ability of the client/caregiver to support care in the home.
• Assigns accurate and compliant ICD‑10-CM diagnosis codes for all home health and hospice patients based on clinical documentation, assessment findings, and regulatory guidelines.
• Oversees the progress of the client during the home health episode of care and monitors care events that may trigger a change in care needs.
• Reviews and signs all plan of care orders for home health and hospice clients (Medicare form-485 orders), CTI orders and service orders going to physicians.
• Manages an average active caseload of 125-150 clients (approximately 1800 clients annually).
• Monitors the activity of 300 clinical staff.

Benefits

• Tuition Reimbursement Program ($6,000 per year based upon Full or Part Time status).
• Employee discounts to various activities, services, and vendors.
• Free employee parking.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree