Quality Assurance Nurse

Quality Assurance Nurse

1. Review Initial Assessment and Reassessment Packets Verify that all required documentation is complete accurate and included before assessment.

2. Initial Assessment Requirements: Initial Assessment

Clinical Records

Physicians Report (LIC 602)

Medication Records

History & Physical (H&P)

Progress Notes

3. Reassessment Requirements: Reassessment

Clinical Records

Physicians Report (LIC 602)

Initial ALW Assessment

Medication Administration Records (MAR)

History & Physical (H&P)

Progress Notes

Incident Reports (when applicable)

Individualized Service Plan (ISP)

4. Create MedCompass Client Assessment and ISP Create a MedCompass shells for newly enrolled clients and existing clients scheduled for semi-annual reassessments ensuring all required demographic and assessment information is prepared for assessment.

5. Conduct Quality Assurance Reviews Review completed initial assessments and reassessments done by RNs to ensure documentation is complete accurate internally consistent and aligned across all supporting clinical records.

6. Transcribe Clinical Assessments into MedCompass Accurately enter assessment data and supporting clinical information into the MedCompass system while maintaining compliance with documentation standards and organizational guidelines.

7. Communicate Clinical Concerns Identify and escalate discrepancies missing documentation or clinical concernsincluding recommended or potential tier level changesto the Head of Clinical Services for review and appropriate action.

8. Coordinate Revisions with Nursing Staff Communicate professionally and promptly with nurses regarding required revisions clarifications or missing information identified during the quality assurance review process. Follow up as needed to ensure all documentation is corrected completed and meets organizational and regulatory standards.

9. Conduct Training and Provide Ongoing Support

Train and mentor new nurses on the proper completion of Individualized Service Plans (ISPs) Initial Assessments Reassessments and other clinical documentation within MedCompass. Provide guidance on documentation standards system navigation best practices and regulatory requirements to ensure accurate consistent and compliant records

Were looking for someone who is:

Detail-oriented and organized

Experienced with clinical documentation and quality assurance

Comfortable working with EMRs and healthcare documentation

A strong communicator who collaborates well with clinical teams