Clinical Documentation Specialist

2 days ago


Joliet, Illinois, United States Lightways Hospice and Serious Illness Care Full time
Job Summary

Lightways Hospice and Serious Illness Care is seeking a skilled Documentation Specialist to join our team. As a key member of our clinical staff, you will be responsible for ensuring compliance with regulatory requirements and maintaining accurate medical records.

Key Responsibilities
  • Assist the Admissions Department in completing plans of care, LCDs, and pre-registration forms.
  • Review claims on the Claims Hold Report and follow up with staff on items needed for billing.
  • Develop, implement, and evaluate new methods of documenting to ensure compliance with regulations.
  • Provide education and training to staff on documentation best practices to ensure compliance.
  • Perform audits to ensure compliance with regulations and report findings and follow up plans as needed.
  • Serve on the Quality Assurance committee.
  • Perform General Inpatient Care (GIP) audits and develop reports and plans in conjunction with the IPU Manager.
  • Review medical records to evaluate proper care and treatment.
  • Review admissions for accuracy and completeness, and obtain, track, and report CTIs.
  • Ensure accuracy and timely submission of HIS data, and stay current with HIS operations manual.
  • Ensure timely completion of recertification documentation by clinical staff, track and report patterns of non-compliance to Clinical Leadership, and advise on corrective action plans.
  • Work with the Hospice Quality Administrative Specialist to ensure compliance with closing clinical visits.
Requirements

The successful candidate will be an RN with a minimum of two (2) years of experience and excellent computer skills. They must also have demonstrated skill in all aspects of terminal care with an expertise in pain and symptom management.

This is a full-time position eligible for full benefits after 30 days. Lightways offers medical, dental, vision, a generous paid time off (PTO) plan, and 401k with a matching benefit.



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