Position Title: Associate Professional Documentation Specialist
Position Summary
The primary responsibility of the Associate Professional (AP) Documentation Specialist is to complete accurate and timely weekly progress notes. As needed, the Documentation Specialist will assess member needs, abilities, and interests, and assist in planning, conducting, and facilitating therapeutic vocational, recreational, and community integration programs and units. The role may also include organizing and supporting special events.
This position serves individuals with severe and persistent mental illness and works closely with clinical and quality assurance staff to ensure compliance and documentation excellence.
Educational Requirements
- Bachelor’s degree from an accredited college or university in a human services field OR
- At least two (2) years of pre- or post-bachelor’s MH/DD experience working with the population served
Supervision will be provided by a qualified professional with experience serving the population until the employee meets the two-year experience requirement. The supervisor and employee will develop an individualized supervision plan upon hire, which will be reviewed annually.
Specific Qualifications
- Highly motivated individual with strong verbal and written communication skills (required)
- Ability to complete weekly progress notes guided by consumers’ identified goals
- Strong organizational and time-management skills with the ability to meet documentation deadlines
- Ability to strategize and prioritize workload effectively
Essential Duties and Responsibilities
- Observe and document consumer treatment interventions, behaviors, and progress
- Submit progress notes daily for assigned caseload
- Assist with overseeing program units during staff absences
- Assist in the development, implementation, monitoring, and revision of the Person-Centered Plan (PCP), as needed
- Consult with identified professionals, family members, and other stakeholders; incorporate their input into the Person-Centered Planning process
- Inform all involved stakeholders and monitor consumer relationships in relation to treatment goals
- Work closely with the Quality Assurance & Improvement (QA/QI) Coordinator and Program Director to improve documentation quality and workflow processes
Employment Requirements
- Must be compassionate and willing to receive additional training to effectively interact with individuals with severe and persistent mental illness
Work Environment
- Fast-paced, high-tech, consumer-focused, and innovative clinical setting
- Emphasis on continuous evaluation and process improvement
- Creativity and collaboration are encouraged
Knowledge, Skills, and Abilities
- Knowledge of community-based resources
- Knowledge of NC Medicaid documentation requirements
- Knowledge of client rights
- Ability to manage crisis and emergency situations and utilize conflict-resolution skills
- Basic computer proficiency, including Microsoft Word
- Ability to work collaboratively with the QA/QI Coordinator, Program Director, and/or Qualified Professional (QP) to develop and follow an individualized supervision plan
Work Hours
- Monday–Friday, 8:30 AM – 4:00 PM
Wages
