Healthcare Documentation & EHR Auditor

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 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.