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Medical Documentation Specialist

COMMUNITY SERVICES FOR EVERY1 INC
Buffalo, NY Full Time
POSTED ON 4/19/2025
AVAILABLE BEFORE 6/19/2025
The Nursing Documentation Specialist is responsible for ensuring that all Agency Clinical records and databases are accurate and compliant with all NYS and Agency procedures and regulations. Additionally, the position will be responsible for assisting the Nursing Services Coordinator, Nursing Services Administrator and the Director of Clinical Services in maintaining record compliance with Medication Administration Certifications and Medication Error Tracking and Monitoring.

POSITION RESPONSIBILITIES
  • Completes program-related clerical tasks to include letters, correspondence, memos, records and reports.
  • Completes data entry in Therap, Relias, QuickMar and other relevant databases/tracking systems.
  • Maintains excel spreadsheets to track and trend Medication Administration Certification Compliance and Medication Error Tracking.
  • Reviews Medication Error Reports for agency employees and notifies Registered Nurses/Management staff of employee status.
  • Regularly reviews direct care staff medication administration records to ensure that employees complete initial and annual requirements and are in compliance with OPWDD regulation.
  • Notifies Employees/Registered Nurses/Management of Medication Administration Certification due dates to ensure training compliance.
  • Communicates any training compliance concerns to the Employee, Training Department and Human Resources.
  • Assists with preparing materials for Medication Administration Classes, tracks attendance and provides updates to Nursing and Training Departments.
  • Maintains database of required consent documentation for HealtheLink and Telemed Services.
  • Assists with maintaining clinical databases to ensure files are updated and current.
  • Assists with managing user accounts from the QuickMar System.
  • Participates in monthly nursing meetings to assist with identifying trend areas.
Education and Experience
  • High School Diploma/GED
  • 2 years of office experience with Microsoft Word and Excel; standard office procedures and equipment.
Skills, Knowledge and Abilities
  • Good oral and written communication skills.
  • Ability to follow oral and written directions.
  • Strong organizational skills

Community Services for Every1 has supported the people of our community for over 30 years. Those with intellectual and developmental disabilities, and those who are simply in need. Every day, our efforts support over 2,000 individuals of all abilities, across counties. We are here for Western New Yorkers – all of them.

Helping those in need takes very special people. And those people are the lifeblood of Community Services for Every1. They’re employees who thrive on helping and who have a passion for connecting. Who can form lifelong bonds with the people they support and make the biggest difference in the lives of fellow Western New Yorkers.

Just as we empower those we serve, we strive to empower each other. We support our colleagues through challenges and we collaborate to find the best solutions – and we work hard to help each other grow. Community Services for Every1 offers competitive starting pay based on directly related experience, generous time off, excellent benefits plans and an opportunity to grow!

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