Documentation and Treatment Plan Specialist

Pyramid Healthcare is dedicated to offering the highest quality of care to those we serve. A focus on client-focused care establishes our family of brands as respected leaders in addiction treatment, mental health recovery and eating disorder treatment modalities.

Pyramid Healthcare offers comprehensive behavioral healthcare defined by supportive environments that offer patients the strength they need to overcome life’s challenges. We offer behavioral healthcare services – psychiatry, addiction recovery, mental disorder treatment, etc. – that allow clients at all stages of recovery or rehabilitation to reclaim health and well-being.

Documentation and Treatment Plan Specialist

Location: Newport News, VA

Schedule: Monday through Friday, 9am-5pm

Pay Rate: $22–$28 per hour (based on experience)

About The Role

We are seeking a detail-oriented and knowledgeable Documentation and Treatment Plan Specialist to support documentation quality and compliance within our behavioral health and substance use treatment programs. In this role, you will ensure that clinical records, treatment plans, and progress notes meet payer, regulatory, and program standards—helping maintain audit readiness and overall reimbursement integrity.

Key Responsibilities

• Review clinical documentation, progress notes, and treatment plans daily to ensure accuracy, completeness, and compliance with behavioral health and substance use treatment requirements.
• Identify missing, incomplete, or unclear documentation and communicate directly with clinicians to request updates or corrections.
• Track outstanding documentation needs and monitor completion of requested corrections.
• Escalate repeated, serious, or unresolved documentation concerns to the Clinical Director or Clinical Supervisor when necessary.
• Verify that documentation meets medical necessity and payer requirements, including signatures, dates, required elements, and treatment alignment.
• Maintain organized logs and partner with clinical leadership to identify recurring gaps or compliance risks.
• Uphold confidentiality standards and comply with HIPAA, state regulations, and organizational policies.
• Complete all required trainings and adhere to accreditation/licensing standards.
• Other duties as assigned.
  
  

Supervisory Responsibilities

None.

Required Qualifications

• High School Diploma or GED required; Bachelor’s degree in a human services–related field preferred (psychology, social work, counseling, health information, behavioral health, etc.).
• Minimum two years of experience reviewing clinical documentation in behavioral health, substance use, utilization review, quality assurance, or medical records settings.
• Experience with EHR systems required.
• Strong understanding of behavioral health terminology, treatment plan structure, payer documentation expectations, and medical necessity standards preferred.
• Clinical licensure (CSAC, QMHP, LCSW, LPC, LSATP) or candidates under board-approved supervision strongly preferred.
  
  

Knowledge, Skills & Abilities

• Excellent written and verbal communication skills.
• Strong clinical judgment and understanding of behavioral health documentation standards.
• Analytical and problem-solving abilities to identify and resolve documentation gaps.
• Ability to respond appropriately in crisis or risk situations.
• Working knowledge of federal/state regulations and compliance standards.
• Commitment to confidentiality, accuracy, and professionalism.
  
  

Pyramid CORE Values

We are committed and proud to live our CORE values and use them to inspire those around us. Our employees are expected to align with these values, behaviors, and standards. We are held accountable for upholding these CORE Values: INTEGRITY is striving to be honest, transparent, and ethical when dealing with clients, staff, and the community. DEDICATION is demonstrating an unwavering commitment to always provide exceptional care and support to those we serve is needed daily. COLLABORATION is a steadfast, team-focused approach; working together to achieve excellence. PASSION is genuine, compelling, and relentless desire to improve lives and support Pyramid Healthcare’s mission.

Total Rewards For Full-Time Positions

• Medical, Dental, and Vision Insurance
• Flexible Spending Accounts
• Life Insurance
• Paid Time Off
• 401(k) with Company Match
• Tuition Reimbursement
• Employee Recognition Programs
• Referral Bonus opportunities
• And More!
  
  

Want to know more?

To learn more about Pyramid Healthcare, and how you can achieve personal and professional growth, visit us at: https://bit.ly/Pyramid-Careers.

Pyramid Healthcare, Inc. is proud of its diverse workforce, and is an Equal Opportunity Employer.