Quality Documentation Specialist (RN)

Mays Home Health; McKinney (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

Mays Home Health is seeking a detail-oriented RN Documentation Specialist to support clinical documentation accuracy, quality, and compliance across our home health operations. The role reviews patient records, conducts clinical documentation audits, and educates staff to ensure agency policies and state/federal regulations are followed.

You will collaborate with clinical leadership and QA teams, stay current on regulatory updates, and assist with developing documentation guidelines.

Qualifications

• Current, active RN license in the state of practice.
• At least 1 year of nursing experience preferred.
• Home health, community health, or medical/surgical nursing experience preferred.
• Experience with Homecare Homebase (HCHB) or similar electronic health record systems preferred.
• Strong understanding of clinical documentation and regulatory compliance.
• Intermediate computer skills and the ability to navigate electronic health records.
• Excellent attention to detail, organization, and communication skills.
• Ability to work collaboratively with clinical teams and provide documentation education and support.
• Valid driver's license, reliable transportation, and automobile insurance as required for occasional patient visits.

Responsibilities

• Review and audit clinical documentation to ensure accuracy, completeness, and regulatory compliance.
• Review electronic health records in Homecare Homebase (HCHB), including Plans of Care, visit notes, medication profiles, physician orders, therapy evaluations, authorizations, and other required documentation.
• Identify documentation gaps and work with clinical staff to ensure timely corrections.
• Provide ongoing education and support to nursing staff on documentation standards and best practices.
• Partner with clinical leadership and Quality Assurance teams to improve documentation processes and compliance.
• Assist QAPI leadership with developing and updating documentation guidelines, educational materials, and procedures.
• Monitor documentation practices to ensure compliance with agency policies, HIPAA, and applicable state and federal regulations.
• Stay current on regulatory updates, agency procedures, and HCHB system requirements.
• Collaborate with clinical staff, physicians, and other healthcare professionals to support quality patient care.
• Perform patient visits on an as-needed basis to support urgent patient care needs.

Job description

Central Pyramid is seeking a detail-oriented RN Documentation Specialist to support clinical documentation accuracy, quality, and compliance across our home health operations. This role is responsible for reviewing patient records, conducting clinical documentation audits, and providing education and support to clinical staff to ensure compliance with agency policies and state and federal regulations.

What You’ll Do

• Review and audit clinical documentation to ensure accuracy, completeness, and regulatory compliance.
• Review electronic health records in Homecare Homebase (HCHB), including Plans of Care, visit notes, medication profiles, physician orders, therapy evaluations, authorizations, and other required documentation.
• Identify documentation gaps and work with clinical staff to ensure timely corrections.
• Provide ongoing education and support to nursing staff on documentation standards and best practices.
• Partner with clinical leadership and Quality Assurance teams to improve documentation processes and compliance.
• Assist QAPI leadership with developing and updating documentation guidelines, educational materials, and procedures.
• Monitor documentation practices to ensure compliance with agency policies, HIPAA, and applicable state and federal regulations.
• Stay current on regulatory updates, agency procedures, and HCHB system requirements.
• Collaborate with clinical staff, physicians, and other healthcare professionals to support quality patient care.
• Perform patient visits on an as-needed basis to support urgent patient care needs.

What We’re Looking For

• Current, active RN license in the state of practice.
• At least 1 year of nursing experience preferred.
• Home health, community health, or medical/surgical nursing experience preferred.
• Experience with Homecare Homebase (HCHB) or similar electronic health record systems preferred.
• Strong understanding of clinical documentation and regulatory compliance.
• Intermediate computer skills and the ability to navigate electronic health records.
• Excellent attention to detail, organization, and communication skills.
• Ability to work collaboratively with clinical teams and provide documentation education and support.
• Valid driver's license, reliable transportation, and automobile insurance as required for occasional patient visits.