Chart Audit Nurse

POSITION SUMMARY:

The Chart Audit Nurse (CA Nurse) conducts and coordinates quality assurance and improvement activities through a collaborative approach with Clinical Management. CA Nurses are responsible for all Outcome Assessment Information Sets (OASIS) and Plan of Care (POC) reviews. The CA Nurse promotes communication and collaboration throughout the organization with the purpose of driving an effective quality assurance program. 

What you'll do:

• Reviews clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and POC.
• Reviews POC Updates and Interim Physician Orders for interventions, goals, and process measures to ensure compliance and follow-up.
• Ensures comprehensive accuracy as well as compliance with federal, state regulations and organizational policy when reviewing documentation for appropriate timepoints.
• Utilizes accurate ICD coding and sequencing relating to the patient’s medical condition including co-morbidities based on current coding guidelines as per clinical documentation and physician information.
• Monitors incomplete and overdue documentation to ensure ongoing compliance by utilizing electronic record documentation tracking tools (OASIS Due, OASIS to Complete, OASIS to Review, Missing POC, etc.)
• Assists staff to ensure timeliness and accuracy of documentation and provides support and education when needed.
• Analyzes and monitors clinical documentation to identify trends and recommend improvements to quality.
• Recognizes critical issues and communicates immediately to their immediate supervisor.
• Assists in the development of processes and procedures to ensure quality patient services and compliance of professional standards.
• Demonstrates strong organizational skills, time management and attention to detail.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education including mandatory in-service programs offered by the agency.
• Participates in clinical and/or departmental meetings as requested.
• Adheres to HIPPA laws and always maintains patient confidentiality.
• Conducts other clinical record audits as assigned.
• Performs other duties as assigned.

What you need:

• Graduate of an accredited school of professional nursing
• Currently licensed as an RN through the State Board of Nursing and meets one or more of the following criteria:
  • RN with a bachelor’s degree in nursing and one year of related working experience
  • RN with a Diploma or Associate’s degree with two years related work experience
• Complies with accepted professional standards and principles
• Experience with OASIS, COS-C Certification Preferred. **Medicaid**
• Knowledge and/or home health medical coding, HCS-D Certification
  • Required or must be certified within 3 months of hire

Preferred Education & Experience:

• Knowledge of Home Health Agency policies and principles
• 1-2 years’ experience in a home health environment
• Knowledge of both state and federal home care regulations
• Knowledge of use of electronic medical record.
• Proficiency utilizing Office 365

We believe our employees are our greatest asset! What we offer:

• Competitive salary based on experience
• Comprehensive benefits package includes medical, dental, vision, disability, and life insurance
• 24 days of paid time off
• Paid Company Holidays
• 401k with company match
• Dayforce Wallet - voluntary benefit that gives you access to earned pay
• Wellness program
• Mileage reimbursement
• Tuition reimbursement
• Company issued iPad with electronic health record system
• Online CEU credits
• One-on-one mentoring and 24/7 clinical support
• Excellent career growth opportunities

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

• Frequently required to stand.
• Frequently required to walk.
• Frequently required to sit.
• Continually required to use hands and fingers.
• Frequently required to climb, balance, bend, stoop, kneel or crawl.
• Occasionally required to lift/push light weights (less than 25 pounds).
• Occasionally required to lift/push light weights (greater than 25 pounds).