Clinical documentation specialist [h1.location_city]

Job Description

Job Description

DUTIES AND RESPONSIBILITIES

Intake, Clinical Assessment & Evaluation

• Conduct all required intake screenings and comprehensive clinical assessments (e.g., Psychosocial / Biopsychosocial History, Case Management Needs Assessment, SNAP, ASAM / LOCUS) to determine level of care within required timelines.
• Administer and score standardized screening tools (e.g., GAD-7, PHQ-9, MDQ-7, COWS, SOCRATES, BSI, and additional screeners as required), and ensure updates are completed at appropriate intervals.
• Demonstrate strong person-centered inquiry and assessment skills to gather accurate client information and inform service planning (CMNA, ASAM, LOCUS, IBPA, Crisis Plans, etc.).
• Develop and update Individual Plans of Service (IPOS), inclusive of authorizations based on supportive documentation from intake, screeners, assessments, clinical records, client needs, and person-centered goals.
• Routinely assess treatment progress and readiness for change to adjust IPOS or recommend higher / lower levels of care, additional services, or discharge planning.
• Complete diagnostic / interpretive summaries, Transition Plans, Discharge Summaries, Behavioral Health Consents, Notice of Hearing / Appeals documentation, and other intake-related and clinical documents within required timeframes.
• Provide clinically-informed recommendations for additional mental health or substance use services as indicated.
• Support new client onboarding through participation in orientation and ensuring a smooth entry into services.

Individual & Group Counseling

Case Management & Care Coordination

Documentation, Data Management & Compliance

Authorization & Billing Coordination

Collaboration, Teamwork & Professional Development

REQUIREMENTS – EDUCATION AND EXPERIENCE

Must have a master’s degree.

Must possess a License (Full or Limited) in Social Work, Professional Counseling, or Psychology with a degree (from an institution accredited by one of the Regional Institutional Accrediting Agencies recognized by the Council on Higher Education Accreditation and listed by the U.S. Government Office of Postsecondary Education) in Social Work, Counseling, Psychology, or Human Services.

Documented successful completion and / or development plan for the Certified Alcohol Drug Counselor (CADC) or Certified Alcohol Advanced Drug Counselor (CAADC) offered by the Michigan Certification Board of Addiction Professionals within 30 days of date of employment and continuously maintained CADC or CAADC credentialing or development plan.

Minimum of two years of experience in mental health, substance use disorder treatment, human services, or the behavioral sciences field.

Effective communication and listening skills, able to interact respectfully, maintain confidentiality, and advocate for clients.

Ability to foster positive relationships, internal and external, with community partners, stakeholders, etc. to enhance the organization's reputation and broaden its reach.

Strong organizational and documentation skills (for record-keeping, case notes, resource coordination).

Agile and flexibility are essential as services may vary day to day.

In-depth knowledge of community resources such as housing, medical, and or needed support services specifically related to the population served.

Group facilitation experience is a plus.

Familiarity with NAMI and community support groups, e.g., 12-step model, etc.

Ability to type 40 words per minute is preferred, with technology proficiency in Microsoft Office products, Google Suite, Zoom, electronic health records, etc.

Ability to collaborate effectively with multidisciplinary colleagues, peers, and teams.

If in recovery, a minimum of 2 years of consistent, verifiable sobriety before application. No active police warrants, and no felony convictions within the past 5 years. With no current cases with the MDOC and the ability to pass a MDOC LEIN clearance.

Demonstrated commitment to ethical and culturally competent care.