Clinical Documentation Specialist

Company:

Providence at Home with Compassus

 

Position Summary

The Clinical Documentation Specialist [Physical Therapist (PT), Occupational Therapist (OT), is responsible for the quality review of all OASIS documents and review of key elements of the Plan of Care to ensure CMS program compliance is met. The Clinical Documentation Specialist works closely with the Manager of Quality Improvement and Home Health leadership to promote regulatory compliance and excellent patient outcomes and reimbursement. The Clinical Documentation Specialist serves as a role model and Oasis expert to Home Health staff across the region.

Position Specific Responsibilities

Position Specific Responsibilities 

• Works in a virtual team environment in a manner that promotes team cohesiveness, efficiency, and productivity. 

• Responsible for the timely review and processing of Start of Care, Resumption of Care, Recertification, and Significant change in Condition Home Health OASIS Assessment documents and key elements of the Plan of Care. 

• Collaborates with leadership to analyze performance trends in OASIS accuracy; assists in determining learning needs for clinical staff. 

• Educates and provides feedback to clinical staff in regard to correct completion of OASIS documents. 

• Reviews of all OASIS data items and ensures accuracy of OASIS based outcome measures to reflect accurate Home Health Quality of Care Star rating and Value Based Purchasing OASIS Based component of TPS. 

• Ensures Regulatory compliance with all OASIS conventions. 

• Ensures timely processing of all OASIS documents to meet CMS guidelines and CMS billing requirements.

• 
   

Education and/or Experience

• Required - Education to meet certification, license or registration requirement.
• Required - 2 years Clinical Experience as a Physical Therapist or Occupational Therapist
• Required - 1 year Home Health Clinical Experience as an PT, OT
• Required - 1 year demonstrated proficiency in Home Health OASIS Review including all types of OASIS
• Required - 1 year Experience with an Electronic Medical Record (EMR) system.
• Required - OASIS Certification within 90 days of hire
• Preferred - 1 year OASIS Review Experience and 1 Year Home Health Clinical Experience

Skills

• Language Skills: Excellent written, oral and interpersonal communication skills.
• Other Skills and Abilities: Working knowledge of home health and CMS requirements for OASIS and Plan of Care for both clinical and billing needs.
• Other Skills and Abilities: Demonstrates ability to coach and mentor staff in one-on-one setting.
• Other Qualifications: Ability to comprehend clinical policies and criteria to clearly articulate requirements surrounding health record information.
• Other Skills and Abilities: Demonstrates analytical and decision making skills.
• Other Skills and Abilities: Ability to prioritize job duties to meet the demands of the day.

Certifications, Licenses, and Registrations

• Required upon hire: Physical Therapist in WA or Compact
• Required upon hire: Occupational Therapist in WA or Compact

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in