Medical Records Reviewer Job at Caregivers, Fort Wayne, IN

bEtIeE16ellvRGI2MU1CRVZOWjBtT3RseHc9PQ==
  • 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

Maiden Home

Interior Design Advisor Job at Maiden Home

 ...furnishings. We are looking for an ambitious and talented Interior Design Advisor to provide world-class consultation and support to...  ...loyalty & retention Work with senior leadership on special projects and initiatives that make the Client Advisory function more efficient... 

Premier Parking Enforcement - New Orleans

Parking Enforcement Agent (Booter) 4:30PM-12:30AM Thurs-Sun Job at Premier Parking Enforcement - New Orleans

 ...Description This job consists of auditing prepaid parking lots in downtown New Orleans to ensure parking patrons have paid to park. Individuals that have not paid will have their vehicle immobilized (boot applied to wheel of vehicle) and charged a fee. Current need... 

SENIOR CARE THERAPY

Clinical Psychologist Job at SENIOR CARE THERAPY

 ...Clinical Psychologist Are you passionate about working with an underserved and rewarding population? Looking for a clinical role without the administrative burden, and one that offers real work-life balance? If so, read on and apply today! Senior Care Therapy is... 

TE Connectivity

LEAD DATA ENGINEER Job at TE Connectivity

 ...connected world. Job Overview At TE we strongly believe that data and analytics are strategic drivers for future success. We are...  ...transportation, energy networks, automated factories, data centers enabling artificial intelligence, and more. Our more than 90,... 

LifeMD

Physician - 1099 Job at LifeMD

 ...is a leading provider of virtual primary care. LifeMD offers telemedicine, laboratory and pharmacy services, and specialized treatment...  ...023 Deloitte Fast 500. About the role We are seeking physicians who are licensed in multiple states and are interested in providing...