Chart Audit Nurse

Posted Tuesday, January 13, 2026 at 5:00 AM

Our Chart Audit Nurses (CA Nurse) conduct and coordinate quality assurance and improvement activities through a collaborative approach with Clinical Management. CA Nurses are responsible for all Outcome Assessment Information Sets (OASIS) and Plan of Care (POC) reviews. The CA Nurse promotes communication and collaboration throughout the organization with the purpose of driving an effective quality assurance program.

• Reviews clinical information for appropriateness, congruency, and accuracy as it relates to the OASIS and POC.
• POC Updates and Interim Physician Orders for interventions, goals, and process measures to ensure compliance and follow-up.
• Ensures comprehensive accuracy as well as compliance with federal, state regulations and organizational policy when reviewing documentation for appropriate time points.
• Utilizes accurate ICD coding and sequencing relating to the patient’s medical condition including co-morbidities based on current coding guidelines as per clinical documentation and physician information.
• Monitors incomplete and overdue documentation to ensure ongoing compliance by utilizing electronic record documentation tracking tools (OASIS Due, OASIS to Complete, OASIS to Review, Missing POC, etc.)
• Assists staff to ensure timeliness and accuracy of documentation and provides support and education when needed.
• Analyzes and monitors clinical documentation to identify trends and recommend improvements to quality.
• Recognizes critical issues and communicates immediately to their immediate supervisor.
• Assists in the development of processes and procedures to ensure quality patient services and compliance of professional standards.
• Demonstrates strong organizational skills, time management and attention to detail.
• Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education including mandatory in-service programs offered by the agency.
• Participates in clinical and/or departmental meetings as requested.
• Adheres to HIPAA laws and always maintains patient confidentiality.
• Conducts other clinical record audits as assigned.
• Performs other duties as assigned.

• Graduate of an accredited school of professional nursing
• Currently licensed as an RN through the State Board of Nursing and meets one or more of the following criteria:
  • RN with a bachelor’s degree in nursing and one year of related working experience
  • RN with a Diploma or Associate’s degree with two years related work experience
• 1-2 years’ Chart Audit or related experience
• OASIS, COS-C Certification Preferred.
  Medicaid
• Knowledge and/or home health medical coding, HCS-D Certification
  • Required or must be certified within 3 months of hire
• Knowledge of use of electronic medical record

• Knowledge of Home Health Agency policies and principles
• 1-2 years’ experience in a home health environment
• Knowledge of both state and federal home care regulations

• Frequently required to stand.
• Frequently required to walk.
• Frequently required to sit.
• Continually required to use hands and fingers.
• Frequently required climb, balance, bend, stoop, kneel or crawl.
• Occasionally required to lift/push light weights (less than 25 pounds).
• Frequent exposure to blood borne and airborne pathogens or infectious materials.

• Ability to travel locally by car to office(s), events, meetings, etc., as needed (approximately 5% or less of the time).

Innovive Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.