Medical Records Reviewer

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 Youll 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 Managers 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 Were 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

• MondayFriday 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.