Clinical Documentation Specialist

Job 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

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.

• 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

• 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

• 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