Quality Assurance RN (Registered Nurse)

Tech Solutions; Cebu City; On-site; PHP 180,000 - 300,000; Full time

Job summary

Tech Solutions in Cebu City is seeking a Quality Assurance Nurse to review initial assessment packets, ensure documentation is complete, accurate, and aligned across clinical records. The role focuses on QA and maintaining compliance across systems.

The candidate will train nurses on ISPs, perform MedCompass data entry, and elevate discrepancies to the Head of Clinical Services for timely action.

Qualifications

• Must be detail-oriented and well-organized.
• Experience with clinical documentation and quality assurance.
• Comfortable working with EMRs and healthcare documentation.
• Strong communication and collaboration with clinical teams.

Responsibilities

• Review initial assessment and reassessment packets for completeness and accuracy.
• Verify required documents are present (Initial Assessment, Clinical Records, Physician's Report LIC 602, MAR, H&P, Progress Notes).
• Transcribe and input clinical assessments into MedCompass accurately.
• Identify discrepancies or missing documentation and escalate to Head of Clinical Services.
• Create MedCompass shells for new and returning clients for reassessments.
• Conduct QA reviews of completed assessments for consistency across records.
• Provide training and ongoing support to nurses on ISP completion and documentation standards.

Skills

Detail-oriented

Clinical documentation

Quality assurance

Strong communicator

Tools

MedCompass

EMR systems

Job description

Quality Assurance Nurse

1. Review Initial Assessment and Reassessment Packets
   • Verify that all required documentation is complete, accurate, and included before assessment.
2. Initial Assessment Requirements:
   • Initial Assessment
   • Clinical Records
   • Physician's Report (LIC 602)
   • Medication Records
   • History & Physical (H&P)
   • Progress Notes
3. Reassessment Requirements:
   • Reassessment
   • Clinical Records
   • Physician's Report (LIC 602)
   • Initial ALW Assessment
   • Medication Administration Records (MAR)
   • History & Physical (H&P)
   • Progress Notes
   • Incident Reports (when applicable)
   • Individualized Service Plan (ISP)
4. Create MedCompass Client Assessment and ISP
   • Create a MedCompass shells for newly enrolled clients and existing clients scheduled for semi-annual reassessments, ensuring all required demographic and assessment information is prepared for assessment.
5. Conduct Quality Assurance Reviews
   • Review completed initial assessments and reassessments done by RNs to ensure documentation is complete, accurate, internally consistent, and aligned across all supporting clinical records.
6. Transcribe Clinical Assessments into MedCompass
   • Accurately enter assessment data and supporting clinical information into the MedCompass system while maintaining compliance with documentation standards and organizational guidelines.
7. Communicate Clinical Concerns
   • Identify and elevate discrepancies, missing documentation, or clinical concerns—including recommended or potential tier level changes to the Head of Clinical Services for review and appropriate action.
8. Coordinate Revisions with Nursing Staff
   • Communicate professionally and promptly with nurses regarding required revisions, clarifications, or missing information identified during the quality assurance review process. Follow up as needed to ensure all documentation is corrected, completed, and meets organizational and regulatory standards.
9. Conduct Training and Provide Ongoing Support
   • Train and mentor new nurses on the proper completion of Individualized Service Plans (ISPs), Initial Assessments, Reassessments, and other clinical documentation within MedCompass. Provide guidance on documentation standards, system navigation, best practices, and regulatory requirements to ensure accurate, consistent, and compliant records

We're looking for someone who is:

• Detail-oriented and organized
• Experienced with clinical documentation and quality assurance
• Comfortable working with EMRs and healthcare documentation
• A strong communicator who collaborates well with clinical teams