LPN RCD Documentation Specialist

About us: Mays Home Health is a provider of home health care services that empower individuals to reach their highest level of independence.
We offer personalized home health care solutions for people who are trying to regain their strength and become independent and are looking to recover from illness, injury and surgery.
The Opportunity: The LPN RCD Documentation Specialist is in cooperation and collaboration with multiple disciplines, as needed, the LPN/LVN RCD Documentation Specialist conducts clinical record audits utilizing agency policy and procedures, federal and state regulations and agency education guides.
The LPN/LVN will be responsible for the RCD (Review Choice Demonstration) documentation review and prepare the documents for submission.
On an emergent basis, for the agency good and patient/client need, the LPN/LVN Documentation Specialist performs patient/client care visits.
Job Responsibilities: 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 Web-based 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 QAPI Director(s), will assist with the development, implementation and revision, as needed, of materials to meet agency policy and state and federal regulations.
6.
Provides ongoing quality documentation education and support to nursing staff according to agency policy.
7.
Complies with accepted professional standards and principles.
8.
Review all elements of the EHR including but not limited to: Plan of Care, Face to Face Encounter Note, Visit Notes, Medication Profile, Calendar, Coordination Notes,Initial Order, Authorization Information (for non-Medicare patients), Therapy Evaluations and Re- Evaluations, Previous Orders, Physician records, etc.
9.
Reviews the EHR of offices.
10.
Provides education to DON/Clinical Supervisor/Field staff on Quality Documentation and chart review findings.
11.
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.
12.
Ensures that QI events such as occurrences and medication errors are entered into database and that the DON is made aware.
Collaborates with the QAPI Director(s) to receive direction on the further action.
13.
Ensures that documentation reflects that field staff and office staff follows protocols and take necessary action to prevent the spread of infectious diseases.
Ensures infection control log is completed when necessary and that DON is made aware.
Collaborates with the QAPI Director(s) to receive direction on the further action.
14.
Participates enthusiastically as a team member that actively supports the short and long-term growth objectives of the office.
15.
Participates in the Influenza Vaccination Program and QAPI activities as assigned by the QAPI Director.
16.
Participates in the Medical Review process when necessary Desired Qualifications: Licensed Practical Nurse or equivalent credential 1+ year of nursing in community/home health or medical/surgical Excellent observation and communication skills Excellent communication and organizational skills Proficient with MS Office Nice-to-Haves: Experience with electronic medical records systems Knowledge of CMS guidelines Knowledge of Home Care Home Base Ability to work independently and as part of a team Ability to multi-task effectively 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 preemployment 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.