Chart Audit Nurse

Innovive Health•Medford, MA

About The Position

Our Chart Audit Nurses (CA Nurse) conduct and coordinate quality assurance and improvement activities through a collaborative approach with Clinical Management. CA Nurses are responsible for all Outcome Assessment Information Sets (OASIS) and Plan of Care (POC) reviews. The CA Nurse promotes communication and collaboration throughout the organization with the purpose of driving an effective quality assurance program. WHAT YOU'LL DO Reviews clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and POC. Reviews POC Updates and Interim Physician Orders for interventions, goals, and process measures to ensure compliance and follow-up. Ensures comprehensive accuracy as well as compliance with federal, state regulations and organizational policy when reviewing documentation for appropriate timepoints. Utilizes accurate ICD coding and sequencing relating to the patient’s medical condition including co-morbidities based on current coding guidelines as per clinical documentation and physician information. Monitors incomplete and overdue documentation to ensure ongoing compliance by utilizing electronic record documentation tracking tools (OASIS Due, OASIS to Complete, OASIS to Review, Missing POC, etc.) Assists staff to ensure timeliness and accuracy of documentation and provides support and education when needed. Analyzes and monitors clinical documentation to identify trends and recommend improvements to quality. Recognizes critical issues and communicates immediately to their immediate supervisor. Assists in the development of processes and procedures to ensure quality patient services and compliance of professional standards. Demonstrates strong organizational skills, time management and attention to detail. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education including mandatory in-service programs offered by the agency. Participates in clinical and/or departmental meetings as requested. Adheres to HIPPA laws and always maintains patient confidentiality.Conducts other clinical record audits as assigned. Performs other duties as assigned

Requirements

Graduate of an accredited school of professional nursing
Currently licensed as an RN through the State Board of Nursing and meets one or more of the following criteria:
RN with a bachelor’s degree in nursing and one year of related working experience
RN with a Diploma or Associate’s degree with two years related work experience
1-2 years’ Chart Audit or related experience
Medicaid Knowledge and/or home health medical coding, HCS-D Certification
Required or must be certified within 3 months of hire
Proficiency utilizing Office 365
Knowledge of use of electronic medical record

Nice To Haves

OASIS, COS-C Certification Preferred.
Knowledge of Home Health Agency policies and principles
1-2 years’ experience in a home health environment
Knowledge of both state and federal home care regulations

Responsibilities

Reviews clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and POC.
Reviews POC Updates and Interim Physician Orders for interventions, goals, and process measures to ensure compliance and follow-up.
Ensures comprehensive accuracy as well as compliance with federal, state regulations and organizational policy when reviewing documentation for appropriate timepoints.
Utilizes accurate ICD coding and sequencing relating to the patient’s medical condition including co-morbidities based on current coding guidelines as per clinical documentation and physician information.
Monitors incomplete and overdue documentation to ensure ongoing compliance by utilizing electronic record documentation tracking tools (OASIS Due, OASIS to Complete, OASIS to Review, Missing POC, etc.)
Assists staff to ensure timeliness and accuracy of documentation and provides support and education when needed.
Analyzes and monitors clinical documentation to identify trends and recommend improvements to quality.
Recognizes critical issues and communicates immediately to their immediate supervisor.
Assists in the development of processes and procedures to ensure quality patient services and compliance of professional standards.
Demonstrates strong organizational skills, time management and attention to detail.
Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education including mandatory in-service programs offered by the agency.
Participates in clinical and/or departmental meetings as requested.
Adheres to HIPPA laws and always maintains patient confidentiality.
Conducts other clinical record audits as assigned.
Performs other duties as assigned