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River Ridge Nursing and Rehabilitation

Behavioral Health Documentation NursePosition Summary:The Behavioral Health Documentation Nurse is responsible for accurately observing, documenting, and reporting resident behaviors in compliance with Montana&rsquo;s Behavioral Add-On Program (BAOP) requirements. This role ensures timely, objective, and detailed charting to support individualized care planning, regulatory compliance, and reimbursement eligibility.Key Responsibilities:Behavior Monitoring &amp; Documentation<ul><li>Observe and document resident behaviors in real time, including frequency, duration, intensity, and triggers.</li><li>Accurately chart behavioral incidents using objective, non-judgmental language.</li><li>Identify and document antecedents, behaviors, and consequences (ABC charting).</li><li>Ensure documentation supports BAOP criteria and reflects medical necessity.</li></ul>Charting &amp; Compliance<ul><li>Complete timely and thorough nursing notes in accordance with facility policy and state regulations.</li><li>Maintain compliance with Montana Medicaid BAOP documentation standards.</li><li>Ensure charting supports care plans, behavioral interventions, and reimbursement requirements.</li><li>Participate in audits and respond to documentation feedback.</li></ul>Care Planning Support<ul><li>Collaborate with interdisciplinary team (IDT) to develop and update behavior care plans.</li><li>Provide input on behavioral patterns, trends, and effectiveness of interventions.</li><li>Document resident response to behavioral interventions and medications.</li></ul>Communication<ul><li>Report significant behavioral changes to providers and care team promptly.</li><li>Communicate with CNAs and staff regarding behavior tracking and documentation expectations.</li><li>Assist in educating staff on proper behavioral documentation techniques.</li></ul>Quality &amp; Risk Management<ul><li>Ensure documentation reduces risk and supports defensible clinical records.</li><li>Monitor for inconsistencies or gaps in behavioral charting and address as needed.</li><li>Support regulatory surveys and compliance reviews.</li></ul>Required Qualifications:<ul><li>Active Montana RN or LPN license</li><li>Experience in long-term care, behavioral health, or psychiatric nursing preferred</li><li>Strong documentation and observational skills</li><li>Knowledge of Medicaid documentation standards (BAOP experience preferred)</li></ul>Preferred Skills:<ul><li>Experience with PointClickCare or similar EHR</li><li>Familiarity with behavior tracking tools (ABC logs, behavior flow sheets)</li><li>Strong attention to detail and critical thinking</li><li>Ability to write clear, objective, and defensible clinical notes</li></ul>Documentation Expectations:<ul><li>Charting must be:</li><li>Objective (what was seen/heard, not opinions)</li><li>Specific (who, what, when, where)</li><li>Consistent with care plan and diagnosis</li><li>Timely (completed during or shortly after event)</li><li>Must clearly support:</li><li>Behavioral diagnosis</li><li>Skilled need</li><li>Intervention effectiveness</li><li>Eligibility for BAOP reimbursement</li></ul>Physical &amp; Work Requirements:<ul><li>Ability to observe residents throughout facility</li><li>Prolonged periods of computer documentation</li><li>Ability to respond to behavioral incidents as needed</li></ul>Pay: $90,000.00 - $100,000.00 per yearBenefits:<ul><li>401(k)</li><li>Dental insurance</li><li>Flexible schedule</li><li>Health insurance</li><li>Paid time off</li><li>Relocation assistance</li></ul>Work Location: Hybrid remote in Billings, MT 59105

Behavior Charting Nurse

Join River Ridge Nursing and Rehabilitation and explore 1   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

River Ridge Nursing and Rehabilitation

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Behavior Charting Nurse