Documentation Specialist

The Enhancement Center; Clayton (NC); On-site; USD 23,000 - 28,000; Full time

Job summary

The Enhancement Center in Clayton, NC is seeking an Associate Professional Documentation Specialist to document consumer treatment interventions, behavior and progress, and submit daily notes on caseload. The role requires strong written and verbal communication and the ability to collaborate with QA/QI and program leadership.

You will work Monday to Friday, 8:30am–4:00pm, with supervision from a qualified professional and opportunities to improve note writing workflows within a fast-paced

Qualifications

• Bachelor’s in human services or 2+ years mh/dd experience with the target population.
• Knowledge of NC Medicaid documentation requirements.
• Ability to document interventions, progress and notes daily.
• Strong verbal and written communication skills.
• Able to work Monday–Friday, 8:30am–4:00pm.
• Supervision provided by a qualified professional with an individualized plan.

Responsibilities

• Complete weekly progress notes.
• Assess member needs and plan appropriate activities.
• Organize and facilitate participation in therapeutic programs/units.
• Collaborate with QA/QI and Program Director on note-writing workflows.

Skills

Documentation

Crisis management

Conflict resolution

Verbal communication

Written communication

Microsoft Word

Education

Bachelor's degree in human services

2 years mh/dd experience

Tools

Microsoft Word

Job description

1. Job Description for an Associate Professional Documentation Specialist

   Educational Requirements:

   Specific Qualifications:

   • Make observations and document consumer treatment interventions, behavior and progress
   • Submit notes daily on caseload
   • Assist with overseeing units on the floor during staff absence
   • Assist with the development, implementation, monitoring and revision of the Person
   Centered Plan (PCP) as it relates to the needs of the individual, as needed
   • Consult with identified professionals, family members and others, include their input in
   the Person-Centered Planning process, inform all involved stakeholders, monitor the
   • Works closely with Quality Assurance & Improvement Coordinator (QA/QI) and Program Director to improve note writing/workflow processes
   
   Must be a compassionate individual willing to be additionally trained to interact with the severe and persistently mentally ill. Fast-paced, high tech, consumer-focused, in an innovative clinical environment, constantly evaluating and improving processes; creativity encouraged.

   Knowledge, Skills and Abilities: Documentation

   – Knowledge of NC Medicaid documentation requirements Ability to handle crisis/emergency situations, and to utilize conflict resolution skills Ability to work with QA/QI Coordinator, Program Director and/or QP to develop and follow an individual supervision plan Monday – Friday 8:30am – 4:00pm

2. Wages: $17.00-$20.00

3. Work Hours:

4. Knowledge of basic computer and applications to include Microsoft Word
5. Knowledge of Client Rights
6. Knowledge of Community Based Resources

7. The work environment is:

8. Employment Requirement:

9. status of the consumer relationships in relation to treatment goals.
10. An individual highly motivated with strong communication skills-- a must have (verbal and written) these skills are critical for overall success as a Documentation Specialist.
11. Graduate of a college or university with a bachelor's degree in a human service field or at least two years pre or post-bachelor's degree accumulated mh/dd/ experience with the population served (this position will work with the severe and persistently mentally ill), Supervision shall be provided by a qualified professional with the population served until the individual meets two years of experience. The supervisor and the employee shall develop an individualized supervision plan upon hiring. The parties shall review the plan annually.
12. The primary job function of the Associate Professional (AP) Documentation Specialist is to complete weekly progress notes. As needed, the Documentation Specialist will assess member needs, abilities and interests, plan, conduct and facilitate involvement in therapeutic vocational, recreation and community integration programs/units and organize special events.