Clinical Quality Assurance Nurse || WFH Role

Job description:

Key Responsibilities

Clinical Documentation Quality Review

• - Review Start of Care (SOC) and admission documentation for completeness, accuracy, and clinical appropriateness.
• - Review Plans of Care (POCs) to ensure that patient needs, diagnoses, goals, interventions, frequency, and services are appropriately documented.
• - Review physician/MD orders for completeness, accuracy, signatures, dates, and consistency with the patient's clinical documentation.
• - Verify that clinical documentation supports the services and care being provided to the patient.
• - Identify missing, inconsistent, or incomplete documentation and coordinate with the appropriate team for correction.
• - Ensure documentation follows established company policies, client requirements, and applicable healthcare standards.

Quality Assurance

• - Conduct routine audits of patient records and clinical documentation.
• - Identify trends, recurring documentation issues, and areas of compliance risk.
• - Document audit findings and provide clear feedback to the appropriate team members.
• - Assist in developing and maintaining QA checklists, audit tools, and quality standards.
• - Participate in process improvement initiatives designed to improve documentation quality and reduce errors.
• - Escalate significant clinical or documentation concerns to the appropriate supervisor or clinical leadership.

Qualifications:

• - Experience in home health, healthcare documentation, clinical review, utilization review, medical auditing, or quality assurance.
• - Strong understanding of nursing documentation and clinical terminology.
• - Proven experience in Start of Care (SOC), Plans of Care (POC), and physician/MD orders.
• - Experience with electronic medical records (EMR/EHR) is preferred.
• - Strong attention to detail and ability to identify inconsistencies or missing information.
• - Excellent written and verbal communication skills.
• - Active Philippine Registered Nurse License

Benefits:

• Health insurance
• Paid training
• Promotion to permanent employee
• Work from home