Medical Documentation Specialist

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.