Benefits:

Flexible schedule

Job Description and Requirements

POSITION: Clinical Documentation Reviewer (Medicaid, CMO, Private) Contractual

REPORTS TO: Clinical Director

SUPERVISES: No Subordinate

Must Reside in the state of Georgia, US

Purpose: The Clinical Documentation Reviewer is responsible for the quality and accuracy of medical record information in the Clinical Assessment.

Duties and Responsibilities:

Ø Read weekly assessments/BIRP notes (Medicaid, CMO and Privates) to ensure that all are co-signed before payroll.

Ø Review assessments/BIRP notes to ensure that documentation is complete, accurate, individualized, and that the documentation supports time billed for each.

Ø Ensure BIRP notes are complete for each assessment billed.

Ø Review of various types of assessments, (Nursing, Psychiatric, Therapeutic)

Ø Ensure appropriate service codes, time in/timeouts, locations, signatures, etc. are on each assessments/BIRP notes.

Ø Ensure diagnosis is supported by the clinical information in the report.

Ø Manage Assessments and Documents location in ShareNote for assessments initiated and follow up with staff to ensure compliance of submission and completion.

Ø Ensure all documentation is signed off per protocol and is audit ready. All documents match the BIRP notes for service codes, time-in/timeouts, units, and locations are signed for the same DOS as well as all new clinicians’ signatures are accurate as to fully/provisionally licensed S/Ts with appropriate credentials.

Ø Ensure appropriate services are recommended based on each individualized assessments/BIRP notes.

Ø Ensure critical assessments/BIRP notes are followed through with connection to appropriate services in a timely manner.

Ø Ensure that Datep clients are referred for nursing assessment, labs, and SA assessments within 10 days of the initial assessment DOS.

Ø Train all new staff on expectations and provide a cheat-sheet to ensure success as a clinician (Nurse, Therapist, Supervisee, Paraprofessional.

Ø Communicate any error trends to staff in a timely manner and update the Clinical Director and Human Resources Director with recommendations for suspension or termination if not meeting standards.

Ø Enforce penalties for grossly late assessments/BIRP notes.

Ø Refer staff for additional training with Clinical Director or provide directly as needed.

Ø Attend monthly staff meeting

Ø Assist during all audits

Ø Provide a method of communication for staff who needs immediate guidance.

Knowledge, Skills, and Abilities Required

Ø Ability to communicate in a professional manner verbally and in writing.

Ø Ability to effectively manage multiple tasks and priorities in a fast-paced environment

Ø Ability to operate independently and collaboratively as part of a tem.

Ø Ability to anticipate, manage, and adapt to change.

Ø Skill and ability to make decisions and solve problems.

Ø Skill and ability to lead and take initiative.

Minimum Job Requirements:

1. Licensed or License-Eligible as a LPC, LMSW, LMFT.

2. Experience completing Assessments, BIRP Notes and Individual Resiliency Plans preferred.

3. Demonstrated knowledge of mental health disorders and treatment methods.

4. Knowledge of clinical operations and procedures, Medicaid services and DBHDD documentation requirements.

5. Experience in quality improvement processes, auditing, and clinical documentation.

6. Exceptional verbal and written communication skills.

Position Requires:

Ø Provision of intensive, integrated, professional mental health services involving treatment planning in a clinical outpatient environment.

Ø Provision of professional leadership in the determination of appropriate therapeutic approaches and methods.

Ø Supervision of the clinical activities of therapists, students, and/or interns within area of specialty

Ø Establishment and maintenance of case files and related documents for clinical and legal purposes

Ø Active attendance in audits, trainings, office hours and meetings relevant and necessary to this position.

Working Conditions and Physical Effort:

Work is normally performed in an interior/office work environment. No or very limited physical effort required. No or very limited exposure to physical risk.

This is a remote position.