LPN/LVN Documentation Specialist

About Us

At Mays, we take pride in the quality service that we provide our patients. If you have a passion for providing excellent care to patients, we want you to be part of our work family. Whether your field is nursing, therapy, personal care, administration, or marketing—at the end of the day, it is all about our patients that we get the honor of serving.

 Full-time benefits include medical, dental, and vision insurance, as well as supplemental insurance with life, paid time off, and generous 401(k) matching. 

LPN/LVN DOCUMENTATION SPECIALIST

This position can be located at any of these branch locations: Ada, Altus, Antlers, Ardmore, Atoka, Broken Bow, Duncan, Durant, Eufaula, Hugo, Idabel, Lawton, Madill, McAlester, Oklahoma City, Okmulgee, Ponca City, Poteau, Sallisaw, Shawnee, Stillwater, Talihina, Tulsa, Vinita, Wagoner, Wetumka, or Yukon.

REPORTS TO: Clinical Compliance Director

MINIMUM QUALIFICATIONS

1. Currently licensed as practical/vocational nurse in the state of practice.

2. Prefer 1 year of nursing experience in health care setting. Community/home health or medical/surgical experience is preferred.

3. Complies with accepted professional standards and practice.

1. Possesses and maintains good physical stamina and mental health. Has completed the agency pre-employment health clearance.

2. Must be a licensed driver with an automobile that is insured in accordance with state and/or Agency requirements and is in good working order.

3. Has satisfactory references from current employers and/or professional peers

4. Have excellent observation and communication skills.

5. Is self-directed with the ability to work with little supervision.

6. Is flexible and cooperative in fulfilling all obligations.

7. Basic computer skills.

8. Demonstrates knowledge of appropriate skills for communicating with individual ages of those served.

9. Demonstrates an ability to work as a team member with professional and administrative personnel.

10. Positive attitude.

11. Excellent interpersonal and phone skills.

12. Assertive and quick. Able to multi-task.

13. Accurate and detailed.

14. Must possess a valid state driver’s license and adhere to all state laws while driving

15. Must possess automobile liability insurance

16. Must have dependable transportation kept in good working condition

17. Must be able to drive an automobile in various types of weather/road conditions

18. Must possess intermediate computer skills

SUMMARY OF JOB RESPONSIBILITIES

In cooperation and collaboration with multiple disciplines, as needed, the LPN/LVN Documentation Specialist conducts clinical record audits utilizing agency policy and procedures, federal and state regulations and agency education guides. On an emergent basis, for the agency good and patient/client need, the LPN/LVN Documentation Specialist performs patient/client care visits.

RESPONSIBILITIES AND DUTIES

1. Provides a positive work environment by consistently modeling in a positive way, the agency philosophy, mission, values, and standards of care, and providing a professional role model for other staff. Ensures office staff and field staff are educated on process and regulatory changes.

2. Adheres to HIPAA regulations and follows agency protocol maintaining confidentiality and does not improperly disclose of patient information.

3. Complies with all agency policies and procedures.

4. Is diligent in activities that ensure advanced proficiency in Homecare Homebase (HCHB) Electronic Health Record (EHR). Actively seeks out training and continuing education in agency processes including participation in offered classroom training and e-learning courses. Communicates as appropriate with staff, physicians, referral sources, community, patients, potential patients, caregivers, and others involved in care.

5. As requested by the Clinical Compliance Director, will assist with the development, implementation and revision, as needed, of materials to meet agency policy and state and federal regulations.

6. Provides Ongoing Education and support according to agency policy

7. Complies with accepted professional standards and principles

8. Ensure patients on services meet criteria established by their payer source such as medical necessity and homebound status and ensure documentation clearly indicates the criteria are met.

9. Ensure assessing clinicians and ancillary staff provides exceptional patient care by utilizing all elements of the nursing process and/or agency standards of care. Ensure the level of care and services provided coincide with the patients’ level of acuity and meet their needs.

10. Ensure assessing clinicians and ancillary staff is providing care within their scope of practice and submits quality documentation authenticating appropriate assessment and intervention provided to the patient.

11. Review all required items such as Visit Note (for information regarding patient status), Medication Profile (to review contraindications), Calendar (to ensure proper disciplines, frequencies, and buddy codes), Coordination Notes (for idea of patient status), Aide Care Plan (for aide services), Supply Requisition, Initial Order (for review), Authorization Information Report (for non-Medicare patients), Therapy Report (to determine likelihood of need for therapy), Previous Orders, Pharmacy Info.

12. Coordinate with Clinical Field Staff Supervisor via email to assist in establishing short and long term therapeutic goals and setting priorities. Receive authorization from the assessing clinician to make necessary edits to reflect an accurate assessment and to provide patient with appropriate pathways, interventions and services.

13. Reviews various types of coordination notes which communicate pertinent patient information or data related to patient care and provision of services.

14. Continues to monitor to ensure these disciplines are following the established plan of care, is compliant with re-assessments within the timelines established by Medicare, providing excellent patient care, providing quality documentation, and meeting the needs of the patient. Reviews discipline only discharges to ensure frequency and goals have been met.

15. Reviews and ensures all orders that address frequency have appropriate calendar modification completed.

16. Ensures supervisory visits of home health aides are scheduled and performed in person, by required discipline, within timelines in compliance with federal regulations.

17. Ensure continuity of care and follow-up with patient as indicated, ensure orders were written as necessary to accommodate patient needs, ensure meds/calendar was updated as indicated, and ensure documentation is thorough.

18. Reviews and processes all wound score deviations ensures appropriate action taken such as coordinating with physician, communicating with staff, patient, and/or caregiver, updating supply needs, and writing orders.

19. Reviews and processes Vital Sign Alert Reports to determine if any patient vital signs fell outside patient specific parameters as established at admission/recert or per subsequent physician order. Reviews EHR to see if physician contact was made by the field nurse and ensure action is documented. Ensures proper care is provided to the patient by following-up on physician notifications and collaborating with them to update the plan of care to include additional visits, update teaching plans, etc. to meet the needs of the patient and then communicate with patients as warranted.

20. Reviews all clinicians’ documentation to ensure excellent care, quality documentation, improving outcomes, and medical necessity to ensure the provision of services and documentation required for financial reimbursement for care completed on a timely basis and in compliance with state and federal regulations.

21. Understands priority is patient care. Must be willing to assist in whatever ways necessary to meet this goal including providing the hands on patient visits - from personal care to skilled care as needed.

22. Ensures Medication errors into the database upon occurrence and collaborate with Clinical Compliance Director to receive direction on further action.

23. Ensures occurrences into the database upon notification and collaborates with Clinical Compliance Director to receive direction on further action.

24. Ensures field staff and office staff follows protocols and take necessary action to prevent the spread of infectious diseases. Ensures infection control report is completed when necessary. Collaborates with the Clinical Compliance Director to receive direction on the further action.

25. Participates enthusiastically as a team member that actively supports the short and long-term growth objectives of the office.

Disclaimer: The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities and will be directed by their Clinical Compliance Director as the need arises.

WORKING CONDITIONS

1. General office.

2. Work is moderate with a combination of sitting, standing, and walking

3. Community and client home environment.

4. Potential exposure to blood and/or body fluids and infectious disease during the performance of job duties.

5. Potential exposure to extreme temperature and humidity when traveling and while in client homes.

6. Potential exposure to dust, gas, fumes, and odors during traveling.

7. This position has been designated as clinical management (see Infection/Exposure Control Plan). Employees performing clinical management duties may be involved in potential exposure to blood borne pathogens and other potentially infectious materials. All clinical management employees will be offered Hepatitis B vaccination at no expense to the employee.

PHYSICAL REQUIREMENTS

1. Visual and manual dexterity is required

2. Good physical stamina and mental health is required. Has completed the agency pre-employment health clearance.

3. Ability to perform tasks involving physical activity, which may include heavy lifting and extensive bending and standing.

4. Ability to deal effectively with stress.

CONTINUING EDUCATION REQUIREMENTS

Must meet the required continuing education hours for state certification as a nurse in Texas as applicable. Agency personnel are expected to participate in appropriate continuing education as may be requested and/or required by their immediate supervisor. In addition, agency personnel are expected to accept personal responsibility for other educational activities to enhance job related skills and abilities. All agency personnel must attend mandatory educational programs.