Medical Record Reviewer Job at Community Home Health Care & CIHC, Fort Wayne, IN

QmlNa1ViZWtKL3NOTjQrbVNMVEtMYW13cEE9PQ==
  • Community Home Health Care & CIHC
  • Fort Wayne, IN

Job Description

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.
What We’re Looking For
  • 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.
  • Previous QA or chart auditing experience preferred, but strong clinical documentation skills will also be considered.
Schedule & Work Environment
  • Monday–Friday schedule, in-office at the Fort Wayne location.
  • Works closely with the Clinical Manager, RN Case Managers, and field staff.
  • Computer-based role with consistent chart auditing and record review responsibilities.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws. We are committed to creating a diverse and inclusive workplace for all employees.

Job Tags

Full time, Work at office, Local area, Trial period, Monday to Friday

Similar Jobs

SENIOR CARE THERAPY

Licensed Clinical Social Worker Job at SENIOR CARE THERAPY

 ...Licensed Clinical Social Worker LCSW Are you passionate about working with an underserved and rewarding population? Looking for a clinical...  ...the geriatric population. We currently serve over 300 Skilled Nursing Facilities including sub-acute, long-term care, and assisted... 

Gigs Inc.

Chief of Staff, Product Job at Gigs Inc.

 ...First principles. We don't ask how things have been done before. We ask why they were done that way at all. The Role As Chief of Staff Product , you will partner with the Head of Product and VP Product to increase the velocity and quality of decision-... 

CRSI

Accounting Manager - Champaign County (Urbana, OH) Job at CRSI

 ...ensure quality, accuracy and efficiency of job performance. Assures Agency's contractual compliance in fiscal matters; monitors service contracts for fiscal compliance, audits, conditions and time lines. In absence of CFO, ensures continued fiscal operations. Attends... 

jub.com

Aviation Project Engineer or Project Designer-EIT Job at jub.com

 ...your experience and network. If you have an interest in civil design, client interaction and construction inspection within the airport engineering field, a career within our Aviation Group may be right for you. Airport Engineering not only focuses on airfield design... 

ICON Plc

Clinical Research Associate II Job at ICON Plc

Clinical Research Associate - Oncology - Chicago ICON plc is a world-leading healthcare intelligence and clinical research organization....  ...progress and escalate risks or issues to the clinical team Assist in tracking site budgets and ensuring timely site payments (as...