Documentation Technician at Community Direct Services

Documentation Technician (Full Time)

Summary: To facilitate, supervise, maintain quality assurance and compliance of documentation as outlined in the policies & procedures of CDS for all Home and Community-Based Settings services offered.

All Documentation Technician team members will be able to provide the following tasks at minimum:

 Case Management- Case management is defined as the maintenance, review, and correction of supported documentation (contact notes) submitted by all staff within your assigned caseload for CDS programs on a two-week rotation schedule. The documentation reviewed will be assessed for its alignment with appropriate ISP goals/objectives. Documentation Technicians are responsible for ensuring all documentation is received into CDS systems within the allotted timeframe and that all required re-submissions are received within the allotted timeframe. The Documentation Technician will also ensure that accurate information is on file for each person within their caseload by auditing each file on a quarterly basis; accurate information includes information outlined on the auditing checklist. Case Management ensures that supported documentation (contact notes) reflect & adhere to the following: Person Centered quality standards, current ISP/treatment plan goals, HCBS, Human Rights, DBHDS, DMAS, and all applicable regulatory rules, laws, and policies. are adhered to. A Documentation Technician will ensure that documentation training is scheduled and provided as needed for support staff that demonstrate challenges with adhering to submission deadlines and/or submitting documentation that aligns with the active ISP; they will also make recommendations for additional skill based training as needed for people receiving supports with a high level of support needs. Documentation Technicians will ensure behavior data is received from support staff as scheduled by the assigned Behavior Consultant on file and that the information is submitted to the assigned Behavior Consultant on file as scheduled. If any of these items are on physical paper, they will be scanned into the Therap system and attached/uploaded to the individual’s file.

1. Billing- Billing is defined as the receipt of all documentation that pertains to hours worked within a particular time period in order to prepare it for billing. The Documentation Technician will maintain all billing documentation according to their assigned caseload(s) as follows:

• Sponsored Residential Case(s): receive billing sheets on a Monthly basis. The support staff that work within this program are able to submit these forms via upload in Therap, fax, or in-person at the office. If they do not bring them to the office monthly, they will need to submit the original copy to their Support Coordinator II during the quarterly visit; Documentation Technician will receive the original from SC II at that time for filing.
• Supportive In-Home Case(s): on a bi-weekly schedule (according to pay-schedule of CDS) the Documentation Technician will use the EVV-Scheduling Report in Therap and compare it against the documentation in order to determine the amount of hours to be billed during that time period. Once the documentation confirms the hours worked, the Documentation Technician will document it accordingly in the respective billing book.
• Companion, Personal Assistance, & Respite Case(s): on a bi-weekly schedule (according to pay-schedule of CDS) the Documentation Technician will use the EVV-Scheduling Report in Therap and compare it against the documentation in order to determine the amount of hours to be billed during that time period. Once the documentation confirms the hours worked, the Documentation Technician will document it accordingly in the respective billing book.

1. On Call Support-On call support is defined as the Documentation Technician providing direct services when necessary. A Documentation Technician will be expected to provide direct services for a case on their caseload after the following has occurred:

• The assigned DSP has called out, fallen ill, etc. and they are unable to find another replacement in a timely manner;

On weekdays, the Documentation Technician will rotate every other day on-call for the entire company. On weekends, only 2 Documentation Technicians will be on-call for the entire company. When the Documentation Technician provides direct services (after 5pm & on the weekend), they will be compensated at their assigned pay rate and will ensure that appropriate and timely documentation is reflected in the data collection records, individual schedules, case notes, monthly summaries, incident reports, etc. are adhered to per DBHDS, Medicaid, and CDS policies & procedure.

1. Professional Development-Professional Development is defined as the attendance of scheduled meetings with Program Director or designee to discuss challenges, case studies, and progress of team activities. The Documentation Technician will attend general staff meetings to receive and share information with CDS team members to evaluate and, if needed, revise training strategies or treatment objectives to improve to quality of life of the individuals participating in CDS programs. The Documentation Technician will also complete at least 6 training hours each year independently in the following areas: ethics (1 hour); person centered practices (2 hours); behavior modification (2 hours); and 1 area of their choosing related to the field of Human Services. These trainings can be conducted virtually and can be recorded videos. They will be documented on a separate form and submitted each year on June 30.

1.  Compliance- Compliance is defined as the Documentation Technician ensuring that staff and all program participants are adhering to required HCBS, Human Rights, DBHDS, DMAS, and all applicable regulatory rules, laws, and policies as outlined in CDS policies & procedures. Documentation Technicians will also make reports to Support Coordinators and Program Directors based on state requirements to satisfy risk management obligations. This will also include participating in required quality assurance & risk analysis teams, groups, etc., as they are scheduled, necessary to review challenges that exist within the infrastructure of CDS, improve services, & mitigate risks, and ensure that DBHDS and DMAS standards are adhered to for reimbursement purposes. The Documentation Technician will abide by company policies and procedures including confidentiality practices and human rights regulations.                                                

1. Other Duties as Required- Other duties as required are defined as the Documentation Technician performing other job duties that require skills, knowledge and physical requirements as demanded by those duties described or less. Individual assignments will be determined by the supervisor based on then current workloads and department needs.

Education/Experience Requirements: minimum of 1-year experience providing support to individuals with intellectual and/or developmental disabilities. Documentation Technician must possess both effective written and interpersonal communications skills. Additionally, Documentation Technicians must be able to work well under pressure and have the capability to work discreetly with highly confidential information such as ISPs.

Knowledge, Skills and abilities: Documentation Technicians are expected to have the following skills:

detail-oriented, dependable, time-management, multitask and troubleshoot. Must possess the ability to lift at least 50lbs. Documentation Technician should also possess strong interpersonal, communication and customer service skills.

Special Requirements: All employees may be expected to work hours in excess of their normally scheduled hours in response to short-term department needs and/or emergencies. May be needed to qualify as QDDP or related designation as required by program.                                                                                

Skills and Abilities: Valid driver’s license and able to transport individuals when necessary. Acceptable time management skills. Good communication & documentation skills. Must be able to work with minimal supervision. Must be computer-savvy and well-versed in Microsoft Office products. Experience using a scanner is also important.

Knowledge of human behavior

Subject to criminal background and child protective services central registry check. 

Positions to be supervised: None