Documentation Specialist - LPN

Signature HealthCARE, LLC; Louisville (KY); On-site; USD 52,000 - 72,000; Full time

Benefits offered by this job

Medical plan

Telemedicine

401(k) and Roth 401(k)

Tuition reimbursement

PTO

Employee discounts

Heart program

Job summary

Signature HealthCARE is seeking a Documentation Specialist to audit medical records, ensure regulatory compliance, and support the Health Information department within an EHR system.

The role requires an active KY LPN/LVN license, 1+ year in long-term care nursing, and knowledge of federal/state regulations. Strong attention to detail, organizational skills, and the ability to multi-task are essential. Shifts vary and include weekends for coverage.

Qualifications

• Current, active LPN/LVN license in KY with multistate privileges.
• CPR/BLS certification preferred (American Heart Association or American Red Cross).
• Minimum one (1) year of clinical nursing experience in long-term care.
• Knowledge of Federal and State long-term care regulations.
• Knowledge of legal, ethical, and professional practice standards as they apply to Health Information Management.
• Knowledge of medical terminology, anatomy and physiology, and regulatory requirements.
• Possess strong analytical, critical thinking, and problem-solving skills.
• Ability to multi-task effectively, manage your time and meet deadlines, and demonstrate strong attention to detail and accuracy.
• Possess excellent organizational skills with ability to prioritize, coordinate, and simultaneously maintain multiple projects with high quality and quantity, without written procedures.

Responsibilities

• Exhibit positive customer service to internal and external customers.
• Conduct detailed audits of medical records to verify presence, accuracy, and completeness of required clinical documentation.
• Conduct detailed audits of MDS and open assessments as needed.
• Review admission observations, events, wound documentation, and discharge documentation.
• Identify documentation deficiencies, omissions, inconsistencies, and opportunities for improvement.
• Track audit results, identify trends, and prepare reports for leadership.
• Assist with record completion processes, physician/provider queries, and follow-up on outstanding documentation.
• Process medical record requests, chart organization, scanning, indexing, and document management activities.
• Maintain confidentiality and security of PHI in accordance with HIPAA and organizational policies.

Skills

Analytical thinking

Problem-solving

Critical thinking

Multi-tasking

Attention to detail

Job description

Signature HealthCARE is a family-based healthcare company offering integrated services across multiple states. Our continuum of care includes skilled nursing, rehabilitation, assisted and memory care, and home-based services supported by innovative technologies like telehealth and Care.ai-enabled solutions.

We are committed to advancing person-directed care and quality outcomes. Many of our facilities continue to receive high performance ratings and accreditations. As an award-winning organization recognized over the years by national outlets such as U.S. News & World Report, we take pride in fostering compassionate care environments and being an employer of choice in the healthcare industry.

Overview

The Documentation Specialist is responsible for reviewing and auditing medical records to ensure documentation is complete, accurate, and compliant with regulatory, payer, and organizational standards. This position also provides essential support to our Health Information department by assisting with organizing, preparing, scanning, and archiving health records into our electronic health record (EHR) system.

How you Will make a difference

• Exhibit positive customer service both to internal and external customers.
• Conduct detailed audits of medical records to verify the presence, accuracy, and completeness of required clinical documentation.
• Conduct detailed audits of MDS and open assessments as needed
• Review admission observations, events, wound documentation, and discharge documentation
• Identify documentation deficiencies, omissions, inconsistencies, and opportunities for improvement.
• Track audit results, identify trends, and prepare reports for leadership.
• Assist with record completion processes, physician/provider queries, and follow-up on outstanding documentation.
• Process medical record requests, chart organization, scanning, indexing, and document management activities
• Maintain confidentiality and security of protected health information (PHI) in accordance with HIPAA and organizational policies.

What you Need to make a Difference

• Current, active LPN/LVN license in KY with multistate privileges.
• CPR/BLS certification preferred (American Heart Association or American Red Cross).
• Minimum one (1) year of clinical nursing experience in long-term, required.
• Knowledge of Federal and State long-term care regulations.
• Knowledge of legal, ethical, and professional practice standards as they apply to Health Information Management.
• Knowledge of medical terminology, anatomy and physiology, and regulatory requirements.
• Possess strong analytical, critical thinking, and problem-solving skills.
• Ability to multi-task effectively, manage your time and meet deadlines, and demonstrate strong attention to detail and accuracy.
• Possess excellent organizational skills with ability to prioritize, coordinate, and simultaneously maintain multiple projects with high level of quality and quantity and without the benefit of written procedures.

*This can be filled in various shift forms

• Five 8 hours shifts
• Four 10 hour shifts
• Three 12 hour shifts

*Every option will include working every Saturday and Sunday

Our exceptional Benefits Package and Signature Perks include the following and more!

• Medical, Dental and Vision – Voluntary Life/Disability
• Free Telemedince with Medical Plan
• 401(K) and Roth 401(K)
• Tuition Forgiveness/Education Reimbursement
• A variety of additional specialized Insurances
• Pay Advance and Next Day Pay!
• Paid Time Off (PTO)
• Partner Perks and Discounts!
• Reward & Recognition Program (HEART)
• Vital Links

At Signature HealthCARE, our team members are permitted – no, encouraged – to employ their talents and abilities to solve problems.
Our culture is built on three distinct pillars: Learning, Spirituality and Intra-preneurship.
Each pillar has its own staff and initiatives, ensuring that our unique culture permeates the entire organization.

Come see what the revolution is all about!

Signature HealthCARE is an Equal Opportunity-Affirmative Action Employer – Minority / Female / Disability / Veteran and other protected categories