Documentation Specialist - LPN

Signature HealthCARE; Louisville (KY); On-site; USD 48,000 - 70,000; Full time

Benefits offered by this job

Medical coverage

Virtual healthcare

401(k) plan

Life insurance

HSA & FSA

PTO & holidays

Tuition assistance

Student debt help

Uniform allowance

Perks discount program

Attendance program

Pay advance

Job summary

Signature HealthCARE is seeking a Documentation Specialist to audit medical records for completeness and regulatory compliance within our long-term care facilities. You will support the Health Information department by organizing, scanning, and archiving records into our EHR system, while maintaining PHI confidentiality and HIPAA adherence.

The role requires an active KY LPN/LVN license, strong analytical skills, and the ability to multitask in a fast-paced environment.

Qualifications

• Current, active LPN/LVN license in KY with multistate privileges.
• CPR/BLS certification preferred (American Heart Association or American Red Cross).
• Minimum one year of clinical nursing experience in long-term care.
• Knowledge of Federal and State long-term care regulations.
• Knowledge of medical terminology, anatomy and physiology, and regulatory requirements.
• Ability to multi-task, meet deadlines, and maintain high quality and accuracy.

Responsibilities

• Review and audit medical records for completeness and accuracy.
• Audit MDS and open assessments as needed.
• Review admission observations, events, wound and discharge documentation.
• Identify deficiencies and opportunities for improvement in documentation.
• Track audit results and prepare reports for leadership.
• Assist with record completion, physician queries, and follow-up on outstanding documentation.
• Process medical record requests, chart organization, scanning, indexing, and document management.
• Maintain confidentiality and PHI in compliance with HIPAA and policies.

Skills

Analytical thinking

Attention to detail

Time management

Communication skills

Education

LPN/LVN license (KY)

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.

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

Live with Purpose at Signature HealthCARE

Our exceptional benefits and Signature Perks are designed to support your health, wealth, and well-being, including:

• Medical, Dental & Vision Coverage
• First Stop Health Virtual Healthcare
• 401(k) & Roth 401(k)
• Company-Paid & Voluntary Life Insurance
• Health Savings Account (HSA) & Flexible Spending Account (FSA)
• Paid Time Off (PTO) & Holiday Incentive Pay
• Tuition Reimbursement & Tuition Discounts with Select Universities
• Student Debt Assistance (eligible SNF RNs & LPNs)
• Uniform Allowance
• Partner Perks Discount Program
• Perfect Attendance Program
• Pay Advance & Next Day Pay
• Employee Assistance Program (EAP)
• Support Beyond Benefits with VitalLink and the Signature Inspire Foundation

At Signature HealthCARE, our team members are empowered—not just encouraged to use their talents and abilities to solve problems.
Our culture is built on three pillars: Learning, Spirituality, and Intra-preneurship.

Each pillar has dedicated initiatives that strengthen our culture and create opportunities for growth.

Come see what the revolution is all about!

Signature HealthCARE is an Equal Opportunity/Affirmative Action Employer. We are committed to creating an inclusive workplace for all applicants and stakeholders.