Documentation Specialist - LPN

Signature HealthCARE, LLC • Jeffersontown, KY

5d

About The Position

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. The role also supports the Health Information department by organizing, preparing, scanning, and archiving health records in the electronic health record (EHR) system.

The position serves internal and external customers and helps maintain the confidentiality and security of protected health information (PHI) in accordance with HIPAA and organizational policies.

Requirements

• Current, active LPN/LVN license in Kentucky with multistate privileges.
• At least one 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 applicable to Health Information Management.
• Knowledge of medical terminology, anatomy and physiology, and regulatory requirements.
• Strong analytical, critical-thinking, and problem-solving skills.
• Ability to multitask, manage time, meet deadlines, and demonstrate attention to detail and accuracy.
• Strong organizational skills, including the ability to prioritize, coordinate, and manage multiple projects while maintaining quality and quantity without written procedures.

Nice To Haves

• CPR/BLS certification from the American Heart Association or American Red Cross is preferred.

Responsibilities

• Provide positive customer service to internal and external customers.
• Audit medical records for the presence, accuracy, and completeness of required clinical documentation.
• Audit 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, physician/provider queries, and follow-up on outstanding documentation.
• Process medical record requests and perform chart organization, scanning, indexing, and document management activities.
• Maintain the confidentiality and security of PHI in accordance with HIPAA and organizational policies.

Benefits

• Medical, dental, and vision coverage.
• First Stop Health virtual healthcare.
• 401(k) and Roth 401(k).
• Company-paid and voluntary life insurance.
• Health Savings Account (HSA) and Flexible Spending Account (FSA).
• Paid time off (PTO) and holiday incentive pay.
• Tuition reimbursement and tuition discounts with select universities.
• Student debt assistance for eligible SNF RNs and LPNs.
• Uniform allowance.
• Partner Perks Discount Program.
• Perfect Attendance Program.
• Pay advance and next-day pay.
• Employee Assistance Program (EAP).
• Support through VitalLink and the Signature Inspire Foundation.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed