Job Summary:
We are looking for a Clinical Review Nurse to help review patient medical records and ensure that the documentation is accurate and meets healthcare standards. The role involves working closely with doctors, nurses, and other healthcare staff to improve patient care and make sure all records follow rules and guidelines.
Key Responsibilities:
- Review Patient Records: Check medical records for completeness, accuracy, and compliance with healthcare regulations.
- Ensure Quality Care: Work with healthcare teams to make sure patient care plans are up to date and well-documented.
- Audit Documentation: Regularly audit patient records to identify errors or gaps and suggest improvements.
- Stay Up-to-Date with Rules: Keep knowledge of healthcare laws, regulations, and documentation standards to ensure compliance.
- Support Healthcare Providers: Help educate staff on proper documentation practices and coding standards.
- Generate Reports: Prepare reports on findings from clinical reviews and share them with management to improve quality.
- Collaborate with Teams: Work closely with medical teams to make sure patient care and records are of the highest quality.
Qualifications:
- Registered Nurse
- Experience with clinical documentation, medical records, and healthcare regulations is a plus.
- Knowledge of medical terminology, coding, and healthcare rules (e.g., ICD-10, CPT).
- Good communication and teamwork skills.
- Attention to detail and the ability to review complex information carefully.
- Proficiency with electronic health records (EHR) and basic computer programs.