Clinical Documentation Auditor
On-siteMargate, Florida, United States
Job Summary
Review clinical documentation across patient charts to ensure accuracy, completeness, and compliance with regulatory, payer, and agency standards. Perform routine audits of Start of Care, Recertification, and Discharge OASIS, visit documentation, Plan of Care compliance, and medication reconciliation. Identify gaps, trends, or inconsistencies in documentation and escalate as appropriate. Collaborate with clinical leadership to provide feedback and education to field staff, and assist in preparing for surveys by regulatory or accrediting bodies. Maintain up-to-date knowledge of CHHA regulations, Medicare Conditions of Participation, and payer documentation requirements.
Required Qualifications
- Licensed RN, LPN, or experienced HHA/QI professional with strong clinical knowledge
- Experience reviewing or auditing charts
- Strong attention to detail and clinical accuracy
- Excellent written and verbal communication
- Critical thinking and ability to identify trends and inconsistencies
- Ability to work independently and collaboratively
- Commitment to patient-centered care and regulatory compliance
Desired Qualifications
- Experience with EMR systems (e.g., HHAeXchange, WellSky, Homecare Homebase)
- Knowledge of PDGM, Medicare audits, and documentation best practices
- Prior quality or compliance experience
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