Documentation Specialist/Auditor

Location: Office
Employment Type: Full-Time/Part-Time
Reports To: Clinical Director/Executive Administrator

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The Documentation Specialist/Auditor is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation within the mental health agency. This role involves auditing client records, training staff on proper documentation procedures, and ensuring adherence to state, federal, and accreditation standards.
Key Responsibilities:
Documentation Review & Auditing:

• · Conduct regular chart audits to ensure compliance with DMAS, DBHDS, Medicaid, and agency policies.
• · Review clinical documentation for accuracy, completeness, and timeliness, including treatment plans, progress notes, and assessments.
• · Identify documentation deficiencies
• · Ensure all records maintain HIPAA compliance and confidentiality.

Compliance & Quality Assurance:

• · Monitor adherence to billing and coding guidelines to prevent errors and potential reimbursement issues.
• · Stay updated on state and federal regulatory changes affecting clinical documentation.
• · Assist in internal and external audits by regulatory agencies and payers.
• · Ensure that all documentation supports medical necessity and appropriate services
• Job Title: Documentation Specialist/AuditorLocation: OfficeEmployment Type: Full-Time/Part-TimeReports To: Clinical Director/Executive AdministratorJob Summary: The Documentation Specialist/Auditor is responsible for ensuring the accuracy, completeness, and compliance of clinical documentation within the mental health agency. This role involves auditing client records, training staff on proper documentation procedures, and ensuring adherence to state, federal, and accreditation standards.Key Responsibilities: Documentation Review & Auditing:
• · Conduct regular chart audits to ensure compliance with

DMAS, DBHDS, Medicaid, and agency policies.
Compliance & Quality Assurance:

• · Monitor adherence to billing and coding guidelines to prevent errors and potential reimbursement issues.
• · Stay updated on state and federal regulatory changes affecting clinical documentation.
• · Assist in internal and external audits by regulatory agencies and payers.
• · Ensure that all documentation supports medical necessity and appropriate service delivery.

Training & Staff Support:

• · Develop guides, templates, and best practice resources to improve documentation quality.
• · Offer individual feedback to management on documentation corrections and improvements.

2 / 2Data Management & Reporting:

• · Maintain records of audit findings, trends, and corrective actions.
• · Generate reports to identify patterns of documentation issues and recommend quality improvement initiatives.
• · Assist with policy development and procedural updates related to documentation standards.

Qualifications & Skills:

• · Required: Associate’s or Bachelor’s degree in Health Information Management, Social Work, Psychology, Healthcare Administration, or a related field.
• · Experience: Minimum 2 years of experience in clinical documentation review, medical records auditing, or compliance within a mental health setting.
• · Strong knowledge of Medicaid/Medicare guidelines, DBHDS/DMAS regulations, and accreditation standards.
• · Proficiency in Electronic Health Records (EHR) systems.
• · Strong attention to detail, analytical skills, and ability to work independently.
• · Excellent communication and training skills.

Preferred Qualifications:

• · Certification in Healthcare Compliance (CHC), Medical Coding (CPC), or Health Information Management (RHIT, RHIA) is a plus.
• · Experience in community-based mental health services (e.g., MHSS, IIH, Crisis Services, PSR).
• · Review clinical documentation for accuracy, completeness, and timeliness, including treatment plans, progress notes, and assessments.
• · Identify documentation deficiencies

· Ensure all records maintain HIPAA compliance and confidentiality.

Pay is negotiable.

Job Types: Full-time, Part-time

Schedule:

• 4 hour shift
• 8 hour shift
• Day shift
• Evening shift
• Monday to Friday
• Weekends as needed

Ability to Commute:

• Petersburg, VA 23805 (Required)

Ability to Relocate:

• Petersburg, VA 23805: Relocate before starting work (Required)

Work Location: In person