A Document Control or Management Specialist manages written and electronic documents for an office or company. Develops or maintains systems for keeping track of documents, including labeling, retrieving, distributing, recovering and destroying documents as needed.
We are seeking a detail-oriented and experienced Quality Assurance Coordinator / Clinical Documentation Specialist with a strong background in home health to join our team. This position is ideal for an individual with extensive knowledge of home health documentation, regulatory compliance, OASIS, and quality assurance processes. The successful candidate will be responsible for reviewing clinical documentation, ensuring regulatory compliance, supporting quality improvement initiatives, and maintaining documentation standards that promote high-quality patient care and survey readiness.
Responsibilities:
Review and audit Plans of Care (POCs), physician orders, skilled nursing notes, therapy documentation, and visit notes for accuracy, completeness, and regulatory compliance. Review OASIS assessments, including Start of Care (SOC), Resumption of Care (ROC), Recertification, Other Follow-Up, Transfer, and Discharge assessments. Audit final discharge records to ensure all required documentation is complete and compliant Ensure documentation complies with Medicare, Medicaid, Conditions of Participation (CoPs), ACHC, AHCA, and agency policies. Identify documentation deficiencies and provide timely feedback and education to clinical staff. Review ICD-10 diagnosis coding for accuracy and appropriate sequencing. Monitor documentation timeliness, record completion, physician order management, and submission requirements. Collaborate with clinical and administrative staff to improve documentation quality, regulatory compliance, and continuity of patient care. Support agency quality improvement initiatives, internal audits, and performance monitoring. Assist in maintaining continuous survey readiness. Maintain HIPAA compliance and protect patient confidentiality. Required Qualifications Home Health experience is required. Minimum of one (1) year of experience in Home Health Quality Assurance, Clinical Documentation Review, OASIS Review, or Medical Records. Strong knowledge of Medicare Home Health regulations and documentation requirements. Experience reviewing Plans of Care (POCs), OASIS assessments, physician orders, and skilled nursing documentation. Working knowledge of ICD-10 diagnosis coding and Medicare Conditions of Participation (CoPs). Excellent attention to detail, organizational, and analytical skills. Ability to work independently, prioritize workload, and consistently meet deadlines. Strong written and verbal communication skills with the ability to provide constructive clinical feedback. Proficiency with Microsoft Office applications. Preferred Qualifications (Not required) Licensed Practical Nurse (LPN) or Registered Nurse (RN). Experience with IGEA . Experience with Medicare chart audits, ADRs, survey preparation, or compliance activities. Why Join Us? Supportive and collaborative team environment. Opportunities for professional growth and advancement. Competitive compensation. Make a meaningful impact by helping ensure high-quality, compliant patient care.
