Clinical Documentation Specialist

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  • Margate, Florida
  • 30+ days ago

    Highlights

    Position Summary: Revival Home Health Care, a certified and respected home health agency, is seeking a dedicated Clinical Documentation Specialist (RN or LPN) to join our Clinical team. Key Responsibilities: Conduct detailed audits of clinical documentation for accuracy, completeness, and regulatory compliance.

    Numbers & Facts

    LocationMargate, Florida

    Description

    Job Title: Clinical Documentation Specialist (RN/LPN) – Full Time
    Location: On-site – Staten Island, NY | Valley Stream, NY | Margate, FL
    Schedule: Monday to Friday, 9:00 AM – 5:00 PM
    Department: Clinical
    Reports To: VP of Clinical Operations
    Company: Revival Home Health Care

    Position Summary:

    Revival Home Health Care, a certified and respected home health agency, is seeking a dedicated Clinical Documentation Specialist (RN or LPN) to join our Clinical team. This is a full-time, on-site role responsible for auditing and reviewing patient charts to ensure compliance with all New York State Department of Health (DOH) regulations and standards, as well as internal clinical documentation policies and procedures.

    Key Responsibilities:

    Conduct detailed audits of clinical documentation for accuracy, completeness, and regulatory compliance

    Review and validate OASIS assessments, visit notes, care plans, and physician orders

    Ensure appropriate and accurate ICD-10 coding aligned with current home health guidelines

    Identify documentation trends and collaborate with clinical staff to provide training and feedback

    Support internal quality assurance and performance improvement initiatives

    Generate audit reports and present findings to leadership for follow-up actions

    Participate in team meetings to support clinical quality improvement efforts

    Maintain up-to-date knowledge of DOH, CMS, and other relevant regulatory updates

    Qualifications:

    Active RN or LPN license in New York State or Florida

    Minimum of 1 year of home health care experience

    Strong knowledge of clinical documentation practices and standards

    OASIS and ICD-10 coding experience strongly preferred

    Exceptional attention to detail and analytical skills

    Strong communication and interpersonal abilities

    Proficiency in EMR systems and Microsoft Office Suite

    Why Join Revival Home Health Care?

    Join a mission-focused team dedicated to excellence in patient care

    Work in a supportive and collaborative clinical environment

    Gain professional development opportunities

    Enjoy a competitive salary and full benefits package

     

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