Position Overview:

The RN Clinical Documentation Reviewer reviews clinical documentation completed by field nurses, tracks completion and submission status, follows up on outstanding records, and supports compliance with agency policies and New York State Department of Health requirements. This position serves as a quality assurance resource by helping ensure clinical records are complete, accurate, timely, and ready for required review and submission.

The Reviewer will work closely with field clinicians, clinical leadership, and support staff to complete and process nursing documentation, physician orders, and related clinical records. While the primary focus of this role is documentation review and quality assurance, occasional field visits may be required based on agency operational or patient care needs.

Responsibilities & Scope:

• Review clinical documentation completed by field nurses in a timely manner, including Start of Care (SOC) Assessments, Reassessments (RA), Change in Condition Assessments, Home Health Aide Supervisory Visits, Care Plans, and related nursing documentation.

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

• Identify missing, inconsistent, unclear, or noncompliant documentation and collaborate with field nurses to obtain required records, corrections, clarification, or supporting documentation needed to complete outstanding items.

• Track documentation status in Medflyt, manage outstanding, incomplete, or missing records, and coordinate documentation workflow to ensure records move through review, correction, processing, and submission within expected timeframes.

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

• Maintain documentation tracking reports and communicate outstanding documentation needs, recurring deficiencies, compliance concerns, trends, or workflow barriers to clinical leadership as appropriate.

• Maintain established productivity and turnaround expectations while ensuring quality and compliance standards are met.

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

• Review current and historical patient records to identify documentation trends, recurring deficiencies, compliance concerns, and opportunities to improve documentation quality.

• Provide feedback and education to field nurses on documentation standards, best practices, recurring opportunities for improvement, and expectations for timely and complete clinical records.

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

• Conduct occasional patient home visits as needed to support agency operations, patient care, or urgent staffing needs.

• Maintain confidentiality of patient information in accordance with HIPAA and agency policies.

Education and Experience:

Required:

• Active and unrestricted New York State Registered Nurse (RN) license.

• Minimum one (1) year of home care experience.

• Knowledge of New York State Department of Health requirements and regulations.

Strongly Preferred:

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

• Experience reviewing nursing documentation for quality and compliance.

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

• Quality assurance or chart audit experience.

Qualifications:

• Strong clinical assessment and documentation review skills, with the ability to evaluate records for completeness, accuracy, timeliness, and compliance.

• Strong understanding of regulatory and quality standards applicable to home care documentation, including the ability to identify potential compliance concerns.

• High attention to detail and strong organizational skills, with the ability to manage multiple records, follow-up items, and documentation deadlines.

• Proficiency with electronic medical record, documentation, or workflow tracking systems.

• Strong written and verbal communication skills, with the ability to clearly explain documentation needs, corrections, and expectations to field clinicians.

• Ability to work independently in a hybrid work environment while maintaining productivity, quality, and turnaround expectations.

• Strong critical thinking and problem-solving skills, with the ability to identify documentation trends, recurring issues, and appropriate next steps.

• Ability to collaborate effectively with field nurses, clinical leadership, and support staff to resolve documentation issues and support timely record completion.

• Ability to provide coaching, feedback, and education to clinicians in a professional and constructive manner.

• Commitment to maintaining confidentiality and handling patient information in accordance with HIPAA and agency policies.

At FreedomCare, base pay is one part of our total compensation package and is determined within a range. This provides our employees with the opportunity to professionally grow and develop within a role. Compensation decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications

At FreedomCare, base pay is one part of our total compensation package and is determined within a range. This provides our employees with the opportunity to professionally grow and develop within a role. The base pay range for this role is between $90,000 and $105,000 per year at the commencement of your first year of employment. Compensation decisions are dependent upon a variety of factors which may include, but are not limited to: skill set, years of relevant experience, education, location, and licensure/certifications.

Compensation Range

$90,000-$105,000 USD