Associate Professional Documentation Specialist

Position Title: Associate Professional Documentation Specialist

Position Summary

The primary responsibility of the Associate Professional (AP) Documentation Specialist is to complete accurate and timely weekly progress notes. As needed, the Documentation Specialist will assess member needs, abilities, and interests, and assist in planning, conducting, and facilitating therapeutic vocational, recreational, and community integration programs and units. The role may also include organizing and supporting special events.

This position serves individuals with severe and persistent mental illness and works closely with clinical and quality assurance staff to ensure compliance and documentation excellence.

Educational Requirements

Bachelor’s degree from an accredited college or university in a human services field OR

At least two (2) years of pre- or post-bachelor’s MH/DD experience working with the population served

Supervision will be provided by a qualified professional with experience serving the population until the employee meets the two-year experience requirement. The supervisor and employee will develop an individualized supervision plan upon hire, which will be reviewed annually.

Specific Qualifications

Highly motivated individual with strong verbal and written communication skills (required)

Ability to complete weekly progress notes guided by consumers’ identified goals

Strong organizational and time-management skills with the ability to meet documentation deadlines

Ability to strategize and prioritize workload effectively

Essential Duties and Responsibilities

Observe and document consumer treatment interventions, behaviors, and progress

Submit progress notes daily for assigned caseload

Assist with overseeing program units during staff absences

Assist in the development, implementation, monitoring, and revision of the Person-Centered Plan (PCP), as needed

Consult with identified professionals, family members, and other stakeholders; incorporate their input into the Person-Centered Planning process

Inform all involved stakeholders and monitor consumer relationships in relation to treatment goals

Work closely with the Quality Assurance & Improvement (QA/QI) Coordinator and Program Director to improve documentation quality and workflow processes

Employment Requirements

Must be compassionate and willing to receive additional training to effectively interact with individuals with severe and persistent mental illness

Work Environment

Fast-paced, high-tech, consumer-focused, and innovative clinical setting

Emphasis on continuous evaluation and process improvement

Creativity and collaboration are encouraged

Knowledge, Skills, and Abilities

Knowledge of community-based resources

Knowledge of NC Medicaid documentation requirements

Knowledge of client rights

Ability to manage crisis and emergency situations and utilize conflict-resolution skills

Basic computer proficiency, including Microsoft Word

Ability to work collaboratively with the QA/QI Coordinator, Program Director, and/or Qualified Professional (QP) to develop and follow an individualized supervision plan

Work Hours

Monday–Friday, 8:30 AM – 4:00 PM

Wages

$17.00 – $20.00 per hour