Medical Records Reviewer Job at Caregivers, Fort Wayne, IN

MVlzNEZHV1BldW4zYy9hRGpKdkxEdCszSGc9PQ==
  • 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

Riot Hospitality Group

Model Server (Bottle Server) Job at Riot Hospitality Group

 ...experience, while maintaining exceptional customer service. The brands under management include Dierks Bentley's Whiskey Row, El Hefe,...  ...true hospitality. This is a general interest application for Model Server (Bottle Server) positions at Riot House Scottsdale. If you... 

Emcube Technologies Inc

Data Governance Analyst Job at Emcube Technologies Inc

 ...Title: Data Governance Analst Location: Chicago, IL / Denver, CO Employment Type: W2 Experienced Data Governance Analst to provide governance oversight for critical data used in applications, reporting, and metrics. Key Responsibilities: Facilitate... 

Gold Star TEFL Recruitment

Kindergarten Teaching Positions in Shenzhen & Guangzhou Job at Gold Star TEFL Recruitment

 ...Excellent salary: 25,000 27,000 RMB per month plus benefits -Teach on a Monday to Friday schedule with evenings & weekends off -Friendly...  ..., supportive teaching environment with excellent materials ESL Jobs in Guangzhou & Shenzhen We are now holding interviews for... 

Cassia

Licensed Practical Nurse LPN 5000 Bonus Job at Cassia

 ...community, soon to be managed by Cassia, is hiring Licensed Practical Nurses (LPNs)to join our dedicated care team. Whether you are...  ...Westhaven began as a Swedish Old Folks Home , dedicated for retired Swedish Evangelical Free Church Pastors. As an integral part... 

SciTec

Help Desk Technician Job at SciTec

 ...Responsibilities include: ~ Delivering support by using SciTecs help desk ticket system through JIRA software. End user requests are...  ...as assigned Examples of day to day tasks: Be the hands and eyes for the remote IT team: rack/stack simple equipment, cable...