Quality Assurance Registered Nurse

WeCare Centers; Town of Herkimer (NY); On-site; USD 80,000 - 110,000; Full time

Job summary

WeCare Centers in New York seeks an experienced Quality Assurance (QA) Nurse – RN to support quality resident care by reviewing clinical documentation, performing assessments, and ensuring that records reflect each resident’s current condition and plan of care.

The ideal candidate brings strong clinical assessment skills, thorough knowledge of nursing documentation, and experience in long-term care or skilled nursing.

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 work with nursing leadership and interdisciplinary teams.

Responsibilities

• Conduct comprehensive clinical assessments of residents.
• Review resident medical records for accuracy, completeness, and consistency.
• Identify changes in condition and documentation gaps.
• Ensure supporting documentation substantiates diagnoses, services, and plans of care.
• Collaborate with nursing and team members to obtain necessary documentation.
• Ensure documentation reflects residents' current status and care needs.
• Perform ongoing audits of clinical documentation and care processes.
• Identify discrepancies, deficiencies, and improvement opportunities.
• Communicate findings to clinical leadership and team members.
• Recommend follow-up or interventions for identified concerns.
• Track issues to ensure timely resolution.
• Support facility quality assurance and performance improvement initiatives.
• Assist in maintaining regulatory compliance and standard procedures.
• Provide education to nursing staff on documentation improvements.

Skills

RN license NY

clinical assessment

nursing documentation

organization

communication

interdisciplinary collaboration

Job description

Quality Assurance (QA) Nurse – RN

Join Our Team

We are seeking an experienced and detail-oriented Quality Assurance (QA) Nurse – RN to join our clinical team. This position plays an important role in supporting quality resident care by reviewing clinical documentation, conducting resident assessments, identifying areas requiring follow-up, and helping ensure that resident records accurately reflect each resident’s current condition and plan of care.

The ideal candidate is a strong clinician with excellent assessment skills, a thorough understanding of clinical documentation, and experience in long-term care or skilled nursing.

Key Responsibilities

As the QA Nurse, you will:

• 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.

Qualifications

Required:

• Current and active Registered Nurse (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 appropriate follow-up

• Ability to work collaboratively with nursing leadership and interdisciplinary teams

Preferred:

• Previous experience in long-term care or skilled nursing

• Quality Assurance/Performance Improvement (QAPI) experience

• Experience conducting clinical documentation audits

• Knowledge of CMS and New York State regulatory requirements

• Familiarity with electronic medical records and long-term care documentation systems

What We're Looking For

We are looking for an RN who sees more than what's written in the chart. The successful candidate will be able to connect clinical findings with documentation, recognize potential gaps, communicate concerns effectively, and follow issues through to resolution.

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We are an Equal Opportunity Employer and consider applicants without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected characteristic in accordance with applicable law.