LPN/RN Documentation Specialist Position Available In Lafayette, Louisiana

LPN/RN Documentation Specialist Maison de

Lafayette Lafayette, LA Job Details Full-time Estimated:

$53.1K – $64.5K a year 1 day ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance 401(k) matching Flexible schedule Life insurance Qualifications Caregiving documentation requirements Medicare RN License ICD coding RAC-CT Mid-level

MDS ICD-10

Quality assurance Attention to detail PointClickCare LPN 2 years Communication skills ARRT (CT)

Certification Full Job Description Job Title:

LPN/RN Documentation Specialist

• Must be an

LPN or RN Position Summary:

The Documentation Specialist Nurse ensures that clinical documentation within the medical record accurately supports MDS assessments, ICD-10 coding, and case-mix components used in the Patient Driven Payment Model (PDPM). This nurse plays a vital role in aligning patient care documentation with Medicare reimbursement criteria and in reducing documentation-related errors that impact reimbursement and compliance.

Primary Responsibilities:

Clinical Documentation Review and Oversight

• Review daily documentation for accuracy, completeness, and clinical relevance in relation to PDPM categories (PT/OT, SLP, Nursing, NTA, and Non-Therapy Ancillary).
• Ensure nursing notes, therapy notes, physician documentation, and supporting assessments substantiate active diagnoses and clinical conditions coded on the MDS.
• Verify documentation of skilled services to support Medicare Part A eligibility and continued stay. Interdisciplinary Coordination
• Collaborate with MDS Coordinators to validate that documentation matches the MDS and ICD-10 coding selections.
• Attend and contribute to daily clinical meetings, Medicare meetings, and care plan meetings to identify changes in condition that impact PDPM reimbursement.
• Communicate documentation needs or deficiencies to nurses, physicians, therapy, and other departments. Education and Training
• Educate nursing and interdisciplinary team members on documentation requirements specific to PDPM categories (e.g., depression indicators, swallowing disorders, comorbidities).
• Provide ongoing in-services and one-on-one training to improve charting practices and awareness of PDPM influences. Audit and Compliance
• Conduct concurrent audits of medical records for accuracy and timeliness.
• Participate audits to ensure compliance with Medicare guidelines and internal standards.
• Identify trends or gaps and assist in developing corrective action plans.

Required Qualifications:

Education:

Graduate of an accredited school of nursing (RN or LPN); RN preferred.

Licensure:

Current nursing license in good standing with the state board.

Experience:

o Minimum 2 years of experience in skilled nursing or long-term care. o Prior experience with MDS documentation, Medicare documentation, or PDPM processes.

Knowledge:

o Strong understanding of PDPM components and documentation triggers. o Familiarity with

MDS 3.0, ICD-10

coding, and skilled nursing documentation standards.

Technical Skills:

Proficiency with EHR and MDS software (e.g., PointClickCare).

Soft Skills:

Excellent attention to detail, strong communication skills, ability to educate others effectively.

Preferred Qualifications:

• RAC-CT certification or equivalent experience with reimbursement/case mix.
• Experience in a documentation quality assurance or clinical compliance role.

Work Environment:

• Fast-paced clinical setting in a skilled nursing facility.
• Primarily desk/office work with routine rounds on units for chart reviews and staff education.
• Occasional flexible hours to support audits or survey readiness.
• Able to work with DON/Administrator to perform other duties as required.

We are an Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment is decided on the basis of qualifications, merit, and business need.

Job Type:

Full-time Expected hours: No less than 40 per week

Benefits:

401(k) 401(k) matching Dental insurance Flexible schedule Health insurance Life insurance Paid time off Vision insurance

Medical Specialty:

Geriatrics Physical Setting:

Long term care Nursing home

Work Location:

In person