RN Clinical Documentation Specialist (OASIS Certified)

Company:

Work Schedule: Monday - Friday 8 a.m. to 5:00 p.m. PST

Position Summary

The Clinical Documentation Specialist RN (Registered Nurse), 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 essential functions of the position.

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.

SERVICE

• 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.

PEOPLE

• 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.
• Works 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 RN license requirements
• Required - 2 years Clinical Experience as a Registered Nurse
• Required - 1 year of Home Health Clinical Experience as a Registered Nurse
• Required - 1 year demonstrated proficiency in Home Health OASIS Review including all types of OASIS
• Preferred - At least 3 months experience with an Electronic Medical Record (EMR) system
• Preferred - OASIS Certification

Certifications, Licenses, and Registrations

• Active and unencumbered Registered Nurse license

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.

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.

Compensation

The current compensation range for this position is $85,000 – $95,000 per year. The specific rate of pay offered to a selected candidate will be determined based on relevant education, training, experience, geographic location, and other position-related factors. Compassus does not inquire about, consider, or rely upon an applicant's prior salary history in determining compensation. In addition to base compensation for the position, an employee working in this position may be eligible for pay differentials based on hours, shifts worked, or other criteria. They may also qualify for bonuses under applicable bonus programs or at Compassus’s discretion, as well as other forms of variable pay under relevant company policies. A summary of applicable pay programs will be provided during the offer process.

Benefits

Compassus offers a comprehensive total rewards package for this position, which may include: medical, dental, and vision insurance; employer-paid life and disability insurance; a 401(k) retirement plan; paid time off and paid holidays; mileage reimbursement; continuing education support; and an Employee Assistance Program. Specific benefit eligibility is determined by employment status and position classification and by the terms of the applicable benefit plan or program. A summary of available benefits will be provided during the offer process.

How to Apply / Application Deadline

Submit your application through the Compassus careers portal at https://www.compassuscareers.com/ or via the platform on which this posting appears. Compassus reserves the right to close this posting at any time, including once a sufficient candidate pool has been identified or an offer has been extended and accepted. Candidates are encouraged to apply promptly.

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