Clinical Documentation Specialist

Clinical Documentation Specialist RN

The Clinical Documentation Specialist RN is responsible for the quality review of all OASIS documents and review of key elements of the Plan of Care to ensure CMS program compliance is met. The Clinical Documentation Specialist works closely with the Manager of Quality Improvement and Home Health leadership to promote regulatory compliance and excellent patient outcomes and reimbursement. The Clinical Documentation Specialist serves as a role model and Oasis expert to Home Health staff across the region.

Position Specific Responsibilities

• The job duties listed are essential functions of the position. However, other duties may be assigned, and may also be considered. The caregiver must be sufficiently fluent in the English language to satisfactorily perform the essential functions of the position. The degree of fluency required will vary depending upon the nature of the position. Caregivers are expected to honor the Mission, Values, Vision and Promise and adhere to the Code of Conduct, policies and standards of their organization. For direct patient care roles: Performs and maintains currency of essential competencies as required by specific area of hire and populations served. Promotes caregiver satisfaction by personal example, treating all contacts with respect. Supports and participates in activities that foster customer service. Communicates and follows the organizational chain of command for notification of patient care/service issues, when appropriate. Maintains required applicable licensure, certification and education. Attends and successfully completes general and department orientation, in-service programs and the annual key competencies and mandatory update requirements. Participates actively in department staff meetings. Demonstrates effective verbal and written communications. Responsible for the timely review and processing of Start of Care, Resumption of Care, Recertification, and Significant Change in Condition Home Health OASIS Assessment documents and key elements of the Plan of Care. Proficiency as a Clinical Documentation Specialist includes the ability to perform Discharge OASIS Review accurately. Collaborates with leadership to analyze performance trends in OASIS accuracy; assists in determining learning needs for clinical staff. Educates and provides feedback to clinical staff in regards to correct completion of OASIS documents. Responsible for the review of all OASIS data items and ensures accuracy of OASIS based outcome measures to reflect accurate Home Health Quality of Care Star rating and Value Based Purchasing OASIS Based component of TPS. Ensures Regulatory compliance with all OASIS conventions. Ensures timely processing of all OASIS documents to meet CMS guidelines and CMS billing requirements. Work in a virtual team environment in a manner that promotes team cohesiveness, efficiency, and productivity. Participates in team meetings, learning opportunities, and other educational opportunities as assigned. Demonstrates continuous learning of OASIS regulations and guidance to stay knowledgeable of current guidance with demonstrated ability to apply guidance to OASIS Review. Achieves and maintains proficiency in OASIS Review including Discharge OASIS Review. Performs other duties as assigned.

Education and/or Experience

• Required- Education to meet and maintain license requirements
• Required 2 years Clinical Experience as a Registered Nurse
• Required 1 year or Home Health Clinical Experience as a Registered Nurse
• Required 1 year Demonstrated proficiency in Home Health OASIS Review including all types of OASIS Required 3 months Experience with an Electronic Medical Record (EMR) system EXPERIENCE Required/Preferred Minimum Experience Details Preferred OASIS Certification Preferred 1 year OASIS Review Experience and 1 Year Home Health Clinical Experience

Skills

• Mathematical Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percentage.
• Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from leaders, team members, investors, and external parties. Strong written and verbal communications.
• Computer Skills: Intermediate computer skills including Microsoft Outlook, Excel, Word, PowerPoint, and willingness to learn new information technology.
• Other Skills and Abilities: Ability to understand, read, write, and speak English. Articulates and embraces integrated healthcare at home philosophy.
• Other Skills and Abilities: Working knowledge of home health and CMS requirements for OASIS and Plan of Care for both clinical and billing needs.
• Other Skills and Abilities: Demonstrates ability to coach and mentor staff in one-on-one setting.
• Other Skills and Abilities: Demonstrates analytical and decision making skills.
• Other Skills and Abilities: Ability to comprehend clinical policies and criteria to clearly articulate requirements surrounding health record information.
• Other Skills and Abilities: Demonstrates proactive identification of problem areas and reports areas of concern to senior management.

Certifications, Licenses, and Registrations

• Required upon hire: Washington Registered Nurse License (Vendor Managed) Or Required upon hire: California Registered Nurse License (Vendor Managed) Or Required upon hire: Oregon Registered Nurse License (Vendor Managed)

Physical Demands and Work Environment: The demands of this role necessitate a team member to effectively perform essential functions. Adaptations can be made to accommodate team members with disabilities. Regular standing, walking, and manual dexterity are fundamental, along with the ability to lift and move objects up to 50 pounds. Visual acuity requirements include close and distance vision, color and peripheral vision, depth perception, and the ability to adjust focus. In a healthcare setting, exposure to bodily fluids, infectious diseases, and conditions typical to the field is expected. Routine use of standard medical equipment and tools associated with clinical care is essential. This description provides a general overview and may vary by role and department, capturing the nuanced demands and conditions inherent to clinical positions in our organization.

At Compassus, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Pay Range:

$0.00 - $0.00

Build a Rewarding Career with Compassus At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others.

Your Career Journey Matters We're dedicated to helping you grow and succeed. Whether you're pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.

The Compassus Advantage

• Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
• Career Development: Access leadership pathways, mentorship, and personalized professional development.
• Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
• Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
• Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
• A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.

Ready to Join? At Compassus, your career is more than a job—it's an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive.