Clinical Documentation Specialist

1 month ago


Guilford, Connecticut, United States Yale-New Haven Health Full time
Job Summary

We are seeking a highly skilled Clinical Documentation Specialist to join our team at Yale-New Haven Health. As a key member of our quality assurance team, you will play a critical role in ensuring the accuracy and completeness of clinical documentation in our home health care services.

Key Responsibilities
  • Conduct comprehensive clinical record reviews to ensure compliance with OASIS and other regulatory requirements
  • Collaborate with coding staff to ensure accurate and complete documentation
  • Develop and conduct educational training programs for clinicians and staff on OASIS requirements and clinical documentation best practices
  • Identify and address documentation issues related to quality of care and ensure compliance with applicable laws and regulations
  • Prepare periodic reports and dashboards to support quality improvement initiatives
Requirements
  • Registered Nurse with active license and BSN preferred
  • At least three years of recent clinical nursing experience, with a minimum of one year of OASIS QA review experience
  • Excellent communication, negotiation, and organizational skills
  • Comprehensive understanding of medical records and data extraction
  • Working knowledge of third-party and prospective payment systems relating to home care and hospice
What We Offer

As a Clinical Documentation Specialist at Yale-New Haven Health, you will have the opportunity to work in a dynamic and collaborative environment, with a focus on delivering high-quality patient care and improving clinical outcomes. We offer a competitive salary and benefits package, as well as opportunities for professional growth and development.



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