Medical Records Reviewer Job at Caregivers, Fort Wayne, IN

ZEtCSStmSG5DYTljRVBJaWxoNTgxNzFKOHc9PQ==
  • 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

LanceSoft

Travel CT Tech Job at LanceSoft

 ...Job Description LanceSoft is seeking a travel CT Technologist for a travel job in White Plains, New York. Job Description & Requirements ~ Specialty: CT Technologist ~ Discipline: Allied Health Professional ~ Start Date: 02/16/2026~ Duration: 13 weeks... 

EisnerAmper

Sr. Manager - Governmental Services (FEMA/Disaster Management & Recovery) Job at EisnerAmper

 ...bottom - we give you the tools you need to succeed and the autonomy to reach your goals. EisnerAmper is seeking a Senior Manager - FEMA in our Government Services practice. Drawing on significant experience with the Federal Emergency Management Agency (FEMA) Public... 

Capital Staffing

Cabinet Finisher Job at Capital Staffing

 ...Job Description Job Description As a Cabinet Finisher you will be responsible for applying finishes, stains, paints, and protective coatings to custom cabinetry and woodwork, ensuring a high-quality, polished appearance that meets our clients' specifications. The... 

Novant Health

Registered Nurse Job at Novant Health

What We Offer: Position: Registered Nurse, RN Schedule: 7:00pm-7:00am, full time, rotating...  ...RN nursing license has been inactive, retired or lapsed for five years or more and you...  ...respond promptly to changes in condition. Work closely with physicians, advanced... 

TBAKI

Environmental Health & Safety (EHS) Specialist - Manufacturing - 2nd Shift Job at TBAKI

 ...Job Description Job Description Role Overview The Environmental Health & Safety (EHS) Specialist supports plant-wide safety, environmental, and regulatory compliance in a fast-paced manufacturing environment. This role plays a hands-on part in OSHA compliance, incident...