Weekend Nurse (LPN or RN) - Documentation Specialist

Job Description

Job Description

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.

Responsibilities

• 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.

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, 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.