Quality Assurance Nurse, RN – Elevate Care & Documentation

WeCare Centers; Town of Herkimer (NY); On-site; USD 70,000 - 90,000; Full time

Job summary

WeCare Centers in New York state is seeking an experienced Quality Assurance (QA) Nurse – RN to join our clinical team. This role focuses on reviewing clinical documentation, conducting resident assessments, and ensuring records reflect each resident’s current condition and plan of care.

The ideal candidate has strong assessment skills, knowledge of CMS and NY regulatory requirements, and experience in long-term care.

Qualifications

• Current and active RN license in New York State.
• Strong clinical assessment and critical-thinking skills.
• Excellent knowledge of nursing documentation and medical records.
• Strong organizational skills and attention to detail.
• Effective written and verbal communication skills.
• Ability to recognize clinical concerns and recommend follow-up.
• Ability to work collaboratively with nursing leadership and interdisciplinary teams.

Responsibilities

• Conduct comprehensive clinical assessments of residents.
• Review resident medical records and clinical documentation for accuracy, completeness, and consistency.
• Identify changes in condition, potential clinical concerns, and documentation gaps.
• Ensure appropriate clinical supporting documentation is present to substantiate resident diagnoses, conditions, services, treatments, and plans of care.
• Work with nursing and interdisciplinary team members to obtain necessary supporting documentation when additional information is required.
• Ensure documentation accurately reflects the resident's current clinical status and care needs.
• Conduct ongoing audits of clinical documentation and resident care processes.
• Identify discrepancies, deficiencies, trends, and opportunities for improvement.
• Communicate findings to appropriate clinical leadership and team members.
• Recommend appropriate follow-up or interventions when clinical or documentation concerns are identified.
• Track identified issues and follow through to ensure timely resolution.
• Support facility quality assurance and performance improvement initiatives.
• Assist in maintaining compliance with applicable regulatory requirements, facility policies, and established clinical standards.
• Provide education and guidance to nursing staff regarding documentation and identified areas for improvement.
• Maintain confidentiality of resident and facility information in accordance with HIPAA and facility policies.

Skills

Clinical assessment

Critical thinking

Documentation knowledge

Organizational skills

Communication skills

Clinical concerns recognition

Interdisciplinary collaboration

Tools

EMR systems

CMS knowledge

Job description

WeCare Centers in New York state is seeking an experienced Quality Assurance (QA) Nurse – RN to join our clinical team. This role focuses on reviewing clinical documentation, conducting resident assessments, and ensuring records reflect each resident’s current condition and plan of care.

The ideal candidate has strong assessment skills, knowledge of CMS and NY regulatory requirements, and experience in long-term care.