IBHS Clinical Documentation Reviewer

Evolving Solution Services; Philadelphia (Philadelphia County); On-site; USD 34,440 - 39,950; Full time

Benefits offered by this job

Paid time off

Supportive team culture

Job summary

Evolving Solution Services is seeking an IBHS Clinical Documentation Reviewer to ensure that clinical documentation meets necessary standards and compliance. This role involves reviewing progress notes, providing feedback to consultants, and supporting quality assurance initiatives.

The ideal candidate will have a Master’s degree in a relevant field and experience within the behavioral health sector. Strong attention to detail and proficiency in documentation standards are essential.

Qualifications

• Master’s degree in a relevant field is required.
• Experience in IBHS or behavioral health services is preferred.
• Strong understanding of documentation standards is essential.

Responsibilities

• Review clinical documentation to ensure compliance with regulations.
• Provide feedback on documentation deficiencies to staff.
• Conduct audits and maintain compliance tracking systems.

Skills

Clinical documentation standards

Behavioral health terminology

Attention to detail

Analytical and problem-solving

Education

Master’s degree in Counseling, Social Work, Psychology, or related field

Tools

Electronic health records (EHR) systems

Microsoft Office

Job description

IBHS Clinical Documentation Reviewer

Full Time Philadelphia, PA, US

Salary Range: $25.00 To $29.00 Hourly

Job Type: Full-Time (W2)

Location: Philadelphia, PA (In-person)

Schedule: Monday – Friday (8:30 AM- 5 PM)

Our Mission

Dunbar Wellness Group, Inc. was founded by a group of dedicated community-based partners. Our mission is to integrate a holistic treatment approach that includes understanding community ecology and social advocacy for children and families in Philadelphia.

In addition, we promote quality therapeutic services that are resiliency and recovery-focused, trauma-informed, and culturally sensitive to the unique needs of urban children and families.

Position Summary

Reporting to the IBHS Clinical Director, the IBHS Clinical Documentation Reviewer is responsible for reviewing and monitoring clinical documentation completed by Behavioral Consultants (BC), Mobile Therapists (MT), and Behavioral Health Technicians (BHT) to ensure compliance with IBHS regulations, agency policies, and payer requirements. The IBHS Clinical Documentation Reviewer will ensure that progress notes are accurate, clinically appropriate, complete, and submitted within required timelines.

The IBHS Clinical Documentation Reviewer supports quality assurance efforts by identifying documentation deficiencies, providing corrective feedback, and promoting high standards of clinical documentation across the IBHS program.

Documentation Review

• The IBHS Clinical Documentation Reviewer will review BC, MT, and BHT progress notes for accuracy, completeness, and compliance.
• Ensure documentation reflects medical necessity, individualized interventions, and measurable progress toward treatment goals.
• Verify that notes include objective observations, appropriate clinical language, and behaviorally specific interventions.
• Monitor documentation for timeliness and completion according to agency and payer requirements.
• Identify missing signatures, incomplete sections, inconsistencies, or compliance concerns.
• Ensure interventions documented align with approved treatment plans and service authorizations.

Quality Assurance & Compliance

• The IBHS Clinical Documentation Reviewer will conduct routine chart audits and documentation quality reviews.
• Ensure compliance with:
  • Pennsylvania IBHS regulations
  • Medicaid and managed care standards
  • HIPAA confidentiality requirements
  • Agency documentation policies
• Maintain tracking systems for documentation compliance and corrective actions.
• Assist with preparation for audits, licensing reviews, and payer requests.

Staff Support & Feedback

• The IBHS Clinical Documentation Reviewer will provide constructive feedback and recommendations to BCs, MTs, and BHTs regarding documentation improvements.
• Collaborate with supervisors and clinical leadership to address recurring documentation issues.
• Support staff training related to clinical documentation standards and best practices.
• Communicate documentation deadlines and compliance expectations to staff as needed.

Qualifications

• Master’s degree in Counseling, Social Work, Psychology, Human Services, or related field required.
• Experience working within IBHS, behavioral health, or children’s mental health services preferred.
• Strong understanding of clinical documentation standards and behavioral health terminology.
• Knowledge of IBHS regulations and medical necessity criteria preferred.Excellent written communication, organization, and attention to detail.
• Ability to work independently and meet deadlines.
• Proficiency with electronic health records (EHR) systems and Microsoft Office.

Preferred Skills

• Experience reviewing progress notes or conducting quality assurance audits.
• Strong analytical and problem‑solving skills.
• Ability to provide professional and supportive feedback to staff.
• Strong time management and organizational abilities.
• In-person, office-based setting.
• Frequent computer and documentation review work.Collaboration with clinical and administrative teams.
• Fast‑paced behavioral health environment requiring professionalism and adaptability.
• Paid time off
• Supportive team culture

Equal Opportunity Employer

Dunbar Wellness Group is an Equal Opportunity Employer committed to fostering an inclusive and supportive workplace for all employees.