Clinical Documentation and Assessment Specialist/Scribe

Updated Position Summary:  The Clinical Documentation and Assessment Specialist supports the Clinical Services Department through completion of live chart audits, administration and documentation of required patient assessments, and monitoring of clinical documentation compliance. Responsibilities include completing and tracking BASIS-32, CABA-Y, and ANSA assessments, identifying documentation deficiencies, and ensuring records meet organizational, regulatory, and accreditation standards. This position serves as a quality and compliance support role and does not provide direct patient care or clinical treatment services.

Report To: Director of Clinical Services

Qualifications: 

    REQUIRED: Associated degree in Behavioral Health, Psychology, Social Work, Healthcare Administration, Nursing, or related field.

    PREFERRED: Bachelor's degree in behavioral health, Psychology, Social Work, Healthcare Administration, Nursing, or related field.

Licensure/Certification/Registration: Must successfully complete ANSA (Adult Needs and Strengths Assessment) training and obtain certification within the first 90 days of employment. Certification must be maintained through annual renewal requirements to ensure ongoing competency, compliance, and proficiency in the administration and documentation of assessments.

Essential Duties and Responsibilities:

• Administer, score, document, and track required patient outcome measures and assessments, including:
• BASIS-32 (Behavior and Symptom Identification Scale)
• CABA-Y (Child and Adolescent Behavior Assessment - Youth)
• ANSA (Adult Needs and Strengths Assessment)
• Ensure assessments are completed within designated timeframes and entered accurately into the medical record.
• Conduct concurrent (live) chart audits to evaluate the accuracy, completeness, and timeliness of clinical documentation throughout a patient's hospitalization.
• Monitor compliance with required clinical documentation standards, including assessments, treatment plans, progress notes, family contacts, discharge planning, and other regulatory requirements.
• Communicate identified documentation deficiencies to clinical staff and leadership in a professional and timely manner.
• Assist with data collection, auditing, and reporting activities related to performance improvement, quality initiatives, regulatory surveys, and accreditation standards.
• Collaborate with therapists, case managers, utilization review staff, nursing, and leadership to support documentation integrity and compliance.
• Participate in departmental quality improvement activities and process improvement initiatives.
• Performs other duties as assigned/required by this position.