Behavior Charting Nurse

Behavioral Health Documentation Nurse

Position Summary:

The Behavioral Health Documentation Nurse is responsible for accurately observing, documenting, and reporting resident behaviors in compliance with Montana’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 & Documentation

• Observe and document resident behaviors in real time, including frequency, duration, intensity, and triggers.
• Accurately chart behavioral incidents using objective, non-judgmental language.
• Identify and document antecedents, behaviors, and consequences (ABC charting).
• Ensure documentation supports BAOP criteria and reflects medical necessity.

Charting & Compliance

• Complete timely and thorough nursing notes in accordance with facility policy and state regulations.
• Maintain compliance with Montana Medicaid BAOP documentation standards.
• Ensure charting supports care plans, behavioral interventions, and reimbursement requirements.
• Participate in audits and respond to documentation feedback.

Care Planning Support

• Collaborate with interdisciplinary team (IDT) to develop and update behavior care plans.
• Provide input on behavioral patterns, trends, and effectiveness of interventions.
• Document resident response to behavioral interventions and medications.

Communication

• Report significant behavioral changes to providers and care team promptly.
• Communicate with CNAs and staff regarding behavior tracking and documentation expectations.
• Assist in educating staff on proper behavioral documentation techniques.

Quality & Risk Management

• Ensure documentation reduces risk and supports defensible clinical records.
• Monitor for inconsistencies or gaps in behavioral charting and address as needed.
• Support regulatory surveys and compliance reviews.

Required Qualifications:

• Active Montana RN or LPN license
• Experience in long-term care, behavioral health, or psychiatric nursing preferred
• Strong documentation and observational skills
• Knowledge of Medicaid documentation standards (BAOP experience preferred)

Preferred Skills:

• Experience with PointClickCare or similar EHR
• Familiarity with behavior tracking tools (ABC logs, behavior flow sheets)
• Strong attention to detail and critical thinking
• Ability to write clear, objective, and defensible clinical notes

Documentation Expectations:

• Charting must be:
• Objective (what was seen/heard, not opinions)
• Specific (who, what, when, where)
• Consistent with care plan and diagnosis
• Timely (completed during or shortly after event)
• Must clearly support:
• Behavioral diagnosis
• Skilled need
• Intervention effectiveness
• Eligibility for BAOP reimbursement

Physical & Work Requirements:

• Ability to observe residents throughout facility
• Prolonged periods of computer documentation
• Ability to respond to behavioral incidents as needed

Pay: $90,000.00 - $100,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible schedule
• Health insurance
• Paid time off
• Relocation assistance

Work Location: Hybrid remote in Billings, MT 59105