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TYPE OF WORK
Full Time
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SALARY
TBD
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HOURS PER WEEK
40
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DATE UPDATED
Jun 22, 2026
Position Summary
The Home Health Quality Assurance (QA) Registered Nurse is responsible for reviewing and auditing patient clinical records to ensure compliance with agency policies, payer requirements, and applicable regulations. The QA RN ensures the accuracy, completeness, and consistency of documentation throughout the patient's episode of care while supporting high-quality patient care and documentation standards.
Essential Duties and Responsibilities
Clinical Record Review and Audit
• Review patient charts for completeness, accuracy, and compliance with agency standards.
• Verify that physician orders are present, signed, dated, and consistent with the patient's plan of care and clinical documentation.
• Ensure physician orders align with nursing, therapy, and interdisciplinary documentation.
• Review patient diagnoses for accuracy, appropriateness, and consistency throughout the medical record.
• Validate that primary and secondary diagnoses support the services provided and documented.
Documentation Quality Assurance
• Review and verify required documentation, including:
? History and Physical (H&P)
? Plan of Care (POC)
? Medication profiles
? Admission documentation
? Visit notes
? Discharge summaries
• Ensure all documentation is complete, accurate, and meets agency and payer requirements.
• Identify missing, inconsistent, or incomplete documentation and communicate deficiencies to clinicians for correction.
Quality Monitoring
• Monitor compliance with applicable home health regulations, payer requirements, and agency policies.
• Review orders, visit notes, and care plans for adherence to home health regulations and agency policies.
• Ensure timely completion of documentation and physician signatures.
• Identify trends, documentation deficiencies, and opportunities for process improvement.
• Collaborate with clinical managers and interdisciplinary tea
Additional Responsibilities
• Track and follow up on outstanding physician orders and documentation corrections.
• Maintain confidentiality and security of patient health information in accordance with HIPAA regulations.
• Support agency readiness for surveys, audits, and accreditation reviews.
• Assist with the implementation of agency policies and quality initiatives as assigned.
Qualifications
• Current Registered Nurse (RN) license in good standing.
• Minimum of 2 years of home health nursing experience preferred.
• Previous Quality Assurance, clinical auditing, or chart review experience preferred.
• Knowledge of home health regulations, documentation standards, and payer requirements.
• Proficiency in electronic medical records (EMR) systems. Experience using Data Soft Logic (DSL) preferred.
• Strong attention to detail, critical thinking, organizational, and communication skills.
