RN Clinical Documentation Reviewer

This is a fully remote position, open to applicants in New York.

📋 Description

• Timely review of clinical documentation submitted by field nurses, including Start of Care (SOC) Assessments, Reassessments (RA), Change in Condition Assessments, Home Health Aide Supervisory Visits, Care Plans, and relevant nursing documentation.

• Assess documentation for completeness, accuracy, clinical relevance, timeliness, and compliance with agency policies, state regulations, quality standards, and New York State Department of Health requirements.

• Identify documentation that is missing, inconsistent, unclear, or noncompliant, and collaborate with field nurses to gather necessary records, corrections, clarifications, or supporting documentation to resolve outstanding items.

• Monitor documentation status in Medflyt, manage any outstanding, incomplete, or missing records, and coordinate the documentation workflow to ensure that records progress through review, correction, processing, and submission within designated timeframes.

• Prepare, process, and submit finalized documentation for physician review and signature in a timely manner.

• Maintain reports on documentation tracking and communicate outstanding documentation needs, recurring deficiencies, compliance issues, trends, or workflow obstacles to clinical leadership as necessary.

• Uphold established productivity and turnaround expectations while ensuring adherence to quality and compliance standards.

• Participate in quarterly audits of clinical records and accurately complete audit tools, quality review forms, and related quality assurance activities for both active and historical patient records within expected timelines.

• Examine current and historical patient records to identify documentation trends, recurring deficiencies, compliance issues, and opportunities for enhancing documentation quality.

• Offer feedback and education to field nurses regarding documentation standards, best practices, recurring areas for improvement, and expectations for timely and complete clinical records.

• Assist with ongoing quality improvement initiatives and regulatory readiness efforts.

• Occasionally conduct patient home visits as necessary to support agency operations, patient care, or urgent staffing requirements.

• Ensure confidentiality of patient information per HIPAA and agency policies.

⛳️ Requirements

• Possession of an active and unrestricted New York State Registered Nurse (RN) license.

• At least one (1) year of experience in home care.

• Familiarity with New York State Department of Health requirements and regulations.

• Experience working in a Licensed Home Care Services Agency (LHCSA).

• Proficiency in reviewing nursing documentation for quality and compliance.

• Experience in using Medflyt or a similar electronic documentation or workflow tracking system.

• Background in quality assurance or chart auditing.

🏝️ Benefits

• Medical, dental, and vision coverage

• Life, short-term disability (STD), and long-term disability (LTD) insurance

• 401(k) match

• Wellness Programs

• Internet Reimbursement

• Gym Reimbursement

• Competitive Compensation

• Continued Education

• Opportunities for growth