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.

Job description

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.

Essential Duties and Responsibilities

Administer, score, document, and track required patient outcome measures and assessments, including BASIS-32, CABA-Y, and ANSA
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

Requirements

Associate degree in Behavioral Health, Psychology, Social Work, Healthcare Administration, Nursing, or related field
Must successfully complete ANSA training and obtain certification within first 90 days of employment
Maintain ANSA certification through annual renewal requirements
Experience administering, scoring, documenting, and tracking patient outcome measures and assessments (BASIS-32, CABA-Y, ANSA)
Experience conducting chart audits and monitoring clinical documentation compliance
Knowledge of regulatory and accreditation standards for clinical documentation
Ability to collaborate with clinical staff and leadership
Data collection, auditing, and reporting skills

Company overview

Universal Health Services, Inc. (UHS) is one of the nation's largest and most respected providers of hospital and healthcare services, operating as a Fortune 300 corporation headquartered in King of Prussia, Pennsylvania. Founded in 1979, UHS has grown into a major healthcare enterprise with approximately 99,000 employees and annual revenues exceeding $14 billion. The company operates through its subsidiaries, managing 29 acute care hospitals, 331 behavioral health facilities, and 60 outpatient and other facilities across 39 U.S. states, Washington D.C., Puerto Rico, and the United Kingdom. UHS provides comprehensive healthcare services including acute care, behavioral health treatment, cancer centers, and ambulatory surgical centers. The company's strategy focuses on building or acquiring high-quality hospitals in rapidly growing markets and investing in advanced medical equipment and skilled personnel to become the leading healthcare provider in each community it serves. UHS is publicly traded on the New York Stock Exchange (NYSE: UHS) and has established a strong reputation for delivering compassionate, high-quality care while maintaining financial stability and operational excellence.