Registered Nurse - Clinical Quality and Chart Review (Wound Care)

Role Overview

We are looking for an experienced RN to support clinical documentation quality, compliance, and audit readiness. This role requires strong critical thinking to identify documentation gaps, potential audit risks, and ensure records support billing and medical necessity.

Key Responsibilities

• Review charts for completeness, accuracy, and compliance
• Verify required elements (rendering provider, signatures, dates)
• Identify documentation gaps and return charts for correction
• Perform pre-billing quality checks (no independent coding changes)
• Assist with audit readiness (organizing and retrieving records)
• Communicate professionally with providers and partner facilities

Important Compliance Notes

• This role does not provide patient care or make treatment decisions
• This role does not independently assign or change billing codes
• All documentation corrections must be completed and signed by the rendering provider

Requirements

• Experience in SNF, home health, wound care, or clinical documentation review preferred
• Strong attention to detail and understanding of documentation requirements
• Experience with EHR systems (NextGen preferred)

Benefits

• Flexible schedule