Clinical Documentation Reviewer

Position: Clinical Documentation Reviewer

Reports to: Clinical Supervisor & Clinical Director

Status: Part-Time, Hybrid (In-Office 3 Days/Week, 1 Remote Day)

Compensation: $16 - $18 per hour

Position Overview:

The Clinical Documentation Reviewer is responsible for reviewing and ensuring the accuracy, compliance, and completeness of all clinical documentation for the agency. This role is critical to maintaining Medicaid standards, agency policies, and billing compliance while supporting therapists in improving their documentation.

This role is fully in-office to ensure timely document review and effective communication with therapists and leadership.

Key Responsibilities:

• Review all clinical notes, CCAs, treatment plans, and discharge summaries for accuracy and Medicaid compliance.
• Ensure documentation meets service definitions and medical necessity requirements for billing approval.
• Track and monitor therapist compliance with documentation deadlines.
• Provide clear feedback and required corrections to therapists regarding documentation errors or deficiencies.
• Identify and report documentation trends to the Clinical Lead for training and corrective action.
• Ensure HIPAA compliance when reviewing and handling clinical records.
• Collaborate with the Clinical Lead and Clinical Director to maintain documentation quality and compliance standards.
• Maintain documentation tracking logs to monitor trends and therapist compliance levels.

Expectations & Performance Metrics:

• Daily review of therapist notes and timely feedback provided.
• Track and ensure 100% compliance with documentation deadlines.
• Work collaboratively with therapists to correct documentation errors within a set timeframe.
• Assist in periodic audits for internal quality control and external Medicaid reviews.
• Maintain an efficient and organized system for tracking and reporting documentation issues.

Qualifications:

• Required: Experience in clinical documentation review, Medicaid compliance, or medical records auditing.
• Preferred: Associate’s or Bachelor’s degree in Social Work, Psychology, Human Services, or a related field.
• Knowledge of Medicaid billing requirements and service definitions.
• Proficiency in Electronic Health Record (EHR) systems.
• Strong attention to detail and ability to meet deadlines.

Why Join Us?

• Fully in-office role for structured workflow and team collaboration.
• Competitive pay with clear performance expectations.
• Opportunity to enhance Medicaid compliance knowledge and quality assurance skills.
• Key role in ensuring accurate and timely billing approvals for the agency

Job Type: Part-time

Pay: $16.00 - $18.00 per hour

Expected hours: No more than 26 per week

Experience:

• Clinical Documentation Review: 1 year (Required)

Work Location: Hybrid remote in Concord, NC 28025

Salary : $16 - $18