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

U.S. Navy

HUMAN RESOURCES MANAGER Job at U.S. Navy

 ...themselves, and that means providing the resources they need to help them advance their...  ...personally, or desire a future career in Human Resources, starting as a Personnel Specialist...  ...with problems or personal hardships Managing your duty stations Career Information... 

BMZ USA, INC

Battery Pack Design Mechanical Engineer Job at BMZ USA, INC

 ...Job Description Job Description Battery Pack Design Mechanical Engineer Battery Pack Design Mechanical Engineer BMZ USA, Inc. develops and produces high-tech lithium-ion battery systems and is looking for a Battery Pack Design Mechanical Engineer to join our... 

Eliassen Group

GRC Business Analyst Job at Eliassen Group

 ...other duties as assigned. Experience Requirements: Experience Requirements Minimum 5 years of experience in business analysis, GRC, risk assessments, systems implementation or enhancements, and IT systems support. Three years working with IAM across enterprise... 

Addison Kenway

Dermatology Nurse Practitioner Job at Addison Kenway

 ...Certified Nurse Practitioner - Dermatology Lexington Park Maryland Job#16651969 We are seeking a full-time experienced Dermatology Nurse Practitioner to work in our privately owned, busy, growing practice in southern Maryland. Must have 1 year of experience in Dermatology... 

Jobconversion, LLC

Remote Data Entry & Admin Assistant Flexible Hours Job at Jobconversion, LLC

 ...A reputable remote work company is seeking data entry clerks for a flexible work-from-home position. Ideal candidates will have accurate typing skills, a minimum typing speed of 30 words per minute, and be proficient in basic PC skills. The pay ranges from $16 to $30 per...