Ensure all documentation meets Medicare and Medicaid Conditions of Participation (COPs), accrediting body recommendations, and state program rules and regulations related to care delivery.
Conduct thorough chart reviews to ensure accuracy, completeness, and compliance at all touchpoints of care.
Verify that all required documentation elements are present, timely, and consistent with internal policies and regulatory standards.
Understand the impact of documentation quality on overall care delivery, branch compliance, and financial integrity.
Support the QA team by identifying documentation gaps, trends, and areas for improvement.
Assist in obtaining care plans, physician orders, and supporting documents necessary to establish medical necessity.
Serve as a professional role model for QA Nurse Team Members and other clinical staff by demonstrating high standards of accuracy, cooperation, conduct, and professionalism.
Maintain strict confidentiality and ensure all patient information is handled in accordance with HIPAA and internal safeguards.
Investigate and escalate documentation-related issues, concerns about clinical performance, or deviations from standards to the Director of Clinical Services.

Bachelor’s degree preferred (Healthcare Administration, Public Health, or related field) or equivalent experience.
Experience in healthcare documentation, quality assurance, medical records, or compliance.
Strong understanding of healthcare regulatory environments (Medicare, Medicaid, state programs) preferred.
Excellent attention to detail and ability to review large volumes of documentation with accuracy.
Strong communication, organization, and problem-solving skills.
Ability to work independently while following structured guidelines and direction from licensed clinical leaders.

QA Documentation Specialist

Key skills