Job Description

Job Description

Job Description

CULTURED CARE, INC.

JOB DESCRIPTION

Clinical Documentation Review Nurse / Quality Assurance Nurse

Reports To: Clinical Manager / Administrator
Position Type: Part-Time
Qualifications: Licensed Practical Nurse

POSITION SUMMARY

The Clinical Documentation Review Nurse is responsible for reviewing, auditing, and monitoring clinical documentation completed by nursing staff to ensure accuracy, completeness, timeliness, regulatory compliance, and consistency with established standards of care.

The nurse supports the agency's Quality Assessment and Performance Improvement (QAPI) program by identifying documentation deficiencies, communicating findings to appropriate clinical personnel, and monitoring corrective actions.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Clinical Documentation Review

• Review skilled nursing notes submitted by Registered Nurses (RNs) and Licensed Practical Nurses (LPNs).
• Verify that nursing documentation is complete, accurate, legible, and submitted within agency-established timeframes.
• Ensure nursing notes accurately reflect services provided, patient assessments, interventions, and responses to treatment.
• Verify documentation is consistent with the physician- or allowed practitioner-approved Plan of Care.
• Identify missing documentation, incomplete assessments, inconsistencies, and discrepancies.
• Confirm required signatures, dates, times, and credentials are present.
• Review documentation for compliance with agency policies and applicable regulatory requirements.

2. Quality Assurance and Compliance

• Conduct routine and periodic audits of clinical records.
• Monitor compliance with CMS Conditions of Participation, CHAP standards, MassHealth requirements, and applicable payer documentation guidelines.
• Identify patterns of documentation deficiencies and report findings to the Clinical Manager.
• Participate in the agency's QAPI activities.
• Assist with preparation for regulatory inspections, accreditation surveys, and internal audits.
• Maintain documentation review records and audit findings.

3. Documentation Corrections and Follow-Up

• Notify clinical staff of incomplete or deficient documentation.
• Request appropriate corrections, clarifications, or addenda in accordance with agency policy.
• Track outstanding documentation deficiencies until resolved.
• Follow up with nursing staff to ensure timely completion of required documentation.
• Escalate unresolved deficiencies to the Clinical Manager.
• Ensure corrections maintain the integrity of the original medical record.

4. Clinical Coordination

• Communicate documentation concerns to the Clinical Manager.
• Identify discrepancies between documented services and authorized nursing services.
• Report potential patient safety concerns identified during chart reviews.
• Assist with identifying opportunities for clinical staff education.
• Support the development of documentation improvement initiatives.

5. Documentation Monitoring and Reporting

• Maintain a Clinical Documentation Review Log.
• Track the number of nursing notes reviewed.
• Document deficiencies identified and corrective actions requested.
• Monitor the timeliness of documentation completion.
• Prepare monthly documentation compliance reports for the Clinical Manager.
• Provide findings and trends for QAPI committee review.

MINIMUM QUALIFICATIONS

• Knowledge of clinical documentation standards.
• Strong organizational skills and attention to detail.
• Ability to maintain patient confidentiality in accordance with HIPAA.
• Proficiency with electronic medical records and clinical documentation systems.

PERFORMANCE EXPECTATIONS

The Clinical Documentation Review Nurse is expected to:

1. Review assigned nursing documentation within agency-established timeframes.
2. Identify and communicate documentation deficiencies promptly.
3. Maintain accurate records of completed documentation reviews.
4. Monitor outstanding documentation corrections.
5. Report recurring documentation deficiencies to the Clinical Manager.
6. Maintain patient confidentiality and professional standards.
7. Support continuous improvement in clinical documentation compliance.

SCOPE OF AUTHORITY

The Clinical Documentation Review Nurse performs documentation review, quality monitoring, and compliance support functions.

The position does not independently modify another clinician's documentation or replace the Clinical Manager's responsibilities for clinical oversight.

Clinical concerns requiring supervisory intervention are referred to the Clinical Manager.

SUPERVISION

The Clinical Documentation Review Nurse reports directly to the Clinical Manager and works collaboratively with nursing staff, administrative personnel, and the agency's quality assurance team.

Cultured Care, Inc. is committed to providing the highest quality in homecare and staffing services. We take pride in our service and have been dedicated to the satisfaction of our clients for over 15 years.

We know that providing care in your home is a personal experience and we strive on providing care with the highest level of dignity and respect.

We provide care for all age groups including pediatrics, adult and seniors. Our skilled nurses are trained and experienced to care for the different needs of our clients. Cultured Care, Inc. is determined to create an open communication relationship with our patients to better serve our clients and assist our clients to achieve their highest possible rehabilitation level.

Cultured Care, Inc.
33 James Reynolds Rd.
Unit E
Swansea, MA 02777

Company Description

Cultured Care, Inc. is committed to providing the highest quality in homecare and staffing services. We take pride in our service and have been dedicated to the satisfaction of our clients for over 15 years. \n\nWe know that providing care in your home is a personal experience and we strive on providing care with the highest level of dignity and respect.\n\nWe provide care for all age groups including pediatrics, adult and seniors. Our skilled nurses are trained and experienced to care for the different needs of our clients. Cultured Care, Inc. is determined to create an open communication relationship with our patients to better serve our clients and assist our clients to achieve their highest possible rehabilitation level. \n\nCultured Care, Inc.\n33 James Reynolds Rd.\nUnit E\nSwansea, MA 02777\n

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