Corporate Clinical Documentation & Chart Audit Specialist (RN/APRN)– Long-Term Care

The Corporate Clinical Documentation & Chart Audit Specialist is responsible for conducting comprehensive chart audits across all long-term care (LTC) providers within the health system. This role ensures accuracy, compliance, and optimization of clinical documentation, billing practices, and regulatory adherence.

The Specialist works collaboratively with providers, facility leadership, and corporate operations to identify documentation gaps, improve provider performance, and support revenue integrity initiatives. This position operates in a hybrid capacity, requiring both in-office presence and remote work, with occasional travel to facilities as needed.

Chart Auditing & Compliance

• Conduct routine and targeted chart audits for LTC providers as directed by corporate leadership
• Evaluate documentation for:
• • Clinical accuracy and completeness
  • Regulatory compliance (federal, state, and payer-specific)
  • Billing and coding alignment
  • Medical necessity and appropriate level of service
• Identify trends, deficiencies, and areas of risk across providers and facilities

Provider Engagement & Education

• Meet directly with providers (in-person or virtual) to review audit findings
• Provide clear, professional feedback with actionable recommendations
• Deliver ongoing education to improve documentation quality, compliance, and productivity
• Support providers in correcting deficiencies and implementing best practices

Tracking, Reporting & Analytics

• Maintain a comprehensive audit tracking system, including:
• • Providers audited
  • Frequency and scope of audits
  • Findings and trends
  • Follow-up actions and outcomes
• Generate regular reports for corporate leadership highlighting:
• • Compliance trends
  • Provider performance
  • Revenue impact and missed opportunities
• Collaborate with leadership to adjust audit focus based on organizational priorities

Operational Collaboration

• Partner with regional and facility leadership, including CEOs, clinic managers, and corporate teams
• Align audit processes with system-wide goals for productivity, compliance, and revenue integrity
• Assist in developing standardized audit tools, scorecards, and workflows
• Participate in process improvement initiatives related to documentation and billing

QUALIFICATIONS:

Education & Experience

• Licensed healthcare professional required (RN or APRN)
• Minimum of 3–5 years of experience in long-term care, clinical documentation, coding, or compliance required
• Experience with chart auditing, EMR systems, and provider documentation review required
• Knowledge of CMS guidelines, Medicare/Medicaid regulations, and LTC billing practices strongly preferred

Skills & Competencies

• Strong analytical and critical thinking skills
• Excellent communication skills with the ability to provide constructive, professional feedback
• High level of organization and ability to manage multiple audits and timelines
• Proficiency in data tracking and reporting (Excel preferred)
• Ability to work independently while collaborating across multiple facilities

Work Environment & Expectations

• Hybrid role: combination of in-office and remote work
• Occasional travel to LTC facilities across the system
• Regular interaction with providers and executive leadership
• High level of confidentiality and professionalism required

Key Performance Indicators (KPIs)

• Audit completion rates and timeliness
• Improvement in provider documentation quality
• Reduction in compliance risks and deficiencies
• Measurable improvement in revenue capture / reduction in missed opportunities
• Provider engagement and follow-through on recommendations

Reporting Structure

• Reports to: Vice President of Long-Term Care Operations
• Works closely with: Corporate compliance, finance, and facility leadership teams (CEOs, Regional LTC Directors and office managers)