Medical Record Reviewer
About The Position
Medical Record Reviewer Community Home Health Care is hiring an in-office QA Nurse to oversee the accuracy, completeness, and regulatory compliance of all clinical documentation. This role is essential to ensuring our client records meet professional standards and support safe, high-quality care. What You’ll Do Clinical Record Audits & Documentation Review Perform monthly audits of skilled nursing notes for all visiting nurses. Provide direct, timely feedback to nurses on missing or incorrect documentation. Re-audit records when deficiencies continue and notify the Clinical Manager as needed. Audit OASIS assessments (SOC, ROC, Recertification, and Follow-Up) prior to transmission. Audit at least 10% of each RN Case Manager’s charts monthly, focusing on recerts, SOC, and ROC visits. Audit all documentation for newly hired RN Case Managers during their probation period. Complete discharge record reviews and notify RN Case Managers when discharge charts need QA review. Deficiency Identification & Follow-Up Review charts for accuracy, completion, legal compliance, and proper care documentation. Document deficiencies on the Case Conference Review form. Notify nurses and department staff of deficiencies and required corrections. Conduct discharge analysis when clients leave the agency. Reporting & Collaboration Track patterns and trends in documentation issues. Communicate concerns and recurring problems to the Clinical Manager. Support corrective action steps when needed. Compile a quarterly audit report summarizing the previous three months. Assist with ongoing chart review processes as assigned.
Requirements
- Active RN license in the State of Indiana.
- Strong understanding of home health documentation standards, Medicare/Medicaid requirements, and OASIS.
- Excellent attention to detail and strong organizational skills.
- Ability to communicate clearly, professionally, and constructively with nursing staff.
- Comfortable working fully in-office in a fast-paced environment.
Nice To Haves
- Previous QA or chart auditing experience preferred, but strong clinical documentation skills will also be considered.
Responsibilities
- Perform monthly audits of skilled nursing notes for all visiting nurses.
- Provide direct, timely feedback to nurses on missing or incorrect documentation.
- Re-audit records when deficiencies continue and notify the Clinical Manager as needed.
- Audit OASIS assessments (SOC, ROC, Recertification, and Follow-Up) prior to transmission.
- Audit at least 10% of each RN Case Manager’s charts monthly, focusing on recerts, SOC, and ROC visits.
- Audit all documentation for newly hired RN Case Managers during their probation period.
- Complete discharge record reviews and notify RN Case Managers when discharge charts need QA review.
- Review charts for accuracy, completion, legal compliance, and proper care documentation.
- Document deficiencies on the Case Conference Review form.
- Notify nurses and department staff of deficiencies and required corrections.
- Conduct discharge analysis when clients leave the agency.
- Track patterns and trends in documentation issues.
- Communicate concerns and recurring problems to the Clinical Manager.
- Support corrective action steps when needed.
- Compile a quarterly audit report summarizing the previous three months.
- Assist with ongoing chart review processes as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
