Medical Records Reviewer Job at Caregivers, Fort Wayne, IN

UU1kQWo0ek5zY2ptN2VXVTYwb2NvRzFSZEE9PQ==
  • Caregivers
  • Fort Wayne, IN

Job Description

Community Home Health Care – Fort Wayne, IN 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.
How to Apply Interested candidates may submit their resume to If you are passionate about maintaining high standards in healthcare documentation and want to make a difference in your community, we invite you to apply and become part of our dedicated team.

Job Tags

Part time, Work at office, Trial period, Monday to Friday,

Similar Jobs

LAW OFFICES OF CHRISTIAN SCHANK AND ASSOCIATES, APC

Family Law Attorney Job at LAW OFFICES OF CHRISTIAN SCHANK AND ASSOCIATES, APC

*Christian Schank and Associates, an established and respected Family Law office, is seeking an experienced Family Law Attorney to join our team!* Description: * The ideal candidate will have experience working in a busy, fast-paced family law firm environment. *... 

Medical City Dallas Hospital - Envision Physician Services

Pediatrics - Emergency Medicine - Physician Job at Medical City Dallas Hospital - Envision Physician Services

 ...benefits package and an outstanding quality of life ~ H1B Visa Sponsorship Provided, if needed Responsibilities Provide high...  ...-time, part-time and independent contractor opportunities available in a variety of community types, from rural and underserved... 

AutoZone

CDL-A Company Driver - 1yr EXP Required - Local - Dry Van - $1.8k per week Job at AutoZone

 ...Follow all DOT regulations to safely deliver merchandise, including hazardous materials. Load and unload pallets at AutoZone stores using an electric pallet jack & hydraulic lift gate. Use on-board systems to create accurate records of activity during delivery.... 

DTCC

Accounting Intern [2026 Internship Program] Job at DTCC

 ...workplace that looks like the world that we serve. About our Internship Program: The Summer Internship Program is a unique and...  ...forefront of DTCCs competitive endeavors across the globe. From accountants and financial analysts to internal consultants and workplace... 

Boeing

Associate Systems Engineer Job at Boeing

 ...inclusive, with great opportunity for professional growth. Find your future with us. The Boeing Company is actively seeking Associate Systems Engineers to join its Saint-Louis based Divisions/Business Units, work locations to include Hazelwood, MO, Saint Charles, MO, or...