Elite Personal Care (EPC)
Audit Assistant: Conduct audits of client records using EPC's established chart audit checklist.
Department: Quality Assurance / Compliance
Position Title: Audit Assistant
Location: Indiana
Employment Type: Contract
Reports To: Manager/Business Office Manager
Position Summary
Elite Personal Care (EPC) is seeking a detail-oriented and highly organized Audit Assistant to conduct comprehensive reviews of client records, service authorizations, care plans, and supporting documentation to ensure accuracy, completeness, and adherence to organizational policies and applicable regulatory requirements.
The Audit Assistant will be responsible for conducting semi-annual chart audits, identifying documentation deficiencies, verifying that authorized services align with documented care, and communicating findings to the appropriate team members for corrective action.
The ideal candidate possesses strong analytical skills, experience reviewing healthcare or home and community-based services documentation, and a thorough understanding of documentation standards, confidentiality requirements, and quality assurance practices.
Key Responsibilities
Client Chart Auditing & Documentation Review
- Conduct semi-annual audits of client records using EPC's established chart audit checklist.
- Review client documentation for accuracy, completeness, consistency, and required signatures.
- Verify client identifying information, medical record numbers, and certification periods.
- Identify missing, incomplete, inconsistent, or potentially noncompliant documentation.
- Maintain detailed audit findings, including applicable dates, deficiencies, and supporting comments.
- Ensure audit results are documented accurately and consistently.
Service Authorization & Care Plan Compliance
- Review service authorizations for Attendant Care (ATTC), Home and Community Assistance (HCA), and Structured Family Caregiving.
- Verify authorized service amounts and applicable Structured Family Caregiving levels.
- Confirm documentation appropriately reflects Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs), as applicable.
- Review client care plans to verify the inclusion of three measurable goals, chronic diagnoses, and established task frequencies.
- Verify that daily tasks align with the client's Person-Centered Individualized Support Plan (PCISP).
- Review transportation documentation to identify whether EPC provides transportation services.
Daily Care Log & Clinical Documentation Review
- Audit daily care logs for completeness, accuracy, and consistency with established care plans.
- Verify that documented daily tasks include required frequencies.
- Confirm that patient and employee signatures are present and correspond with the dates services were performed.
- Identify documentation referencing clinical tasks, including seizure care, wound care, ostomy care, catheter care, tube feeding, and medication setup or administration.
- Record identified clinical tasks for appropriate review and follow-up.
- Review LRI claim note documentation and identify missing notes or dates requiring correction, including cases where the client is not an LRI.
Administrative Documentation & Compliance
- Verify the presence and completeness of required client documentation, including:
- Signed client agreements and emergency backup plans.
- Consent to release information and voice recording authorizations.
- Privacy practices acknowledgments and disaster plan acceptance forms.
- Inspect questionnaires and photo consent forms.
- Quarterly client satisfaction reports.
- Missed clock-out signature forms.
- Person-Centered Individualized Support Plans (PCISPs).
- Complaint documentation, when applicable.
- Identify missing documentation and communicate deficiencies to the appropriate personnel.
- Ensure confidential client information is reviewed and maintained in accordance with applicable privacy requirements and company policies.
Discharge Documentation Review
- Review applicable discharge records for required documentation.
- Verify the presence of 30-day discharge letters and certified letter documentation.
- Confirm service authorizations appropriately reflect client discharge status.
- Identify inconsistencies or missing discharge documentation requiring follow-up.
Quality Assurance & Audit Reporting
- Document audit findings using established checklists and internal reporting procedures.
- Communicate documentation deficiencies and discrepancies to designated team members or management.
- Track identified deficiencies and support follow-up efforts to obtain missing documentation or resolve discrepancies.
- Assist in identifying recurring documentation issues and opportunities for process improvement.
- Support organizational efforts to maintain accurate, complete, and audit-ready client records.
- Participate in quality assurance and compliance initiatives as assigned.
Minimum Qualifications
Recommended requirements for this position
- High school diploma or equivalent.
- At least one year of experience in healthcare administration, medical records, documentation review, quality assurance, compliance, or a related field.
- Experience reviewing, maintaining, or auditing client or patient records.
- Strong attention to detail and ability to identify documentation discrepancies.
- Proficiency with Microsoft Office applications, particularly Excel, Word, and Outlook.
- Strong organizational, time-management, and analytical skills.
- Ability to handle confidential and sensitive client information professionally.
- Effective written and verbal communication skills.
- Ability to work independently, prioritize assignments, and meet established deadlines.
Preferred Qualifications
Recommended qualifications to identify stronger candidates
- Associate degree or higher in Healthcare Administration, Health Information Management, Business Administration, or a related discipline.
- Two or more years of experience in healthcare documentation auditing, quality assurance, compliance, or medical records management.
- Previous experience in personal care services, home healthcare, or home and community-based services (HCBS).
- Familiarity with Indiana Medicaid documentation requirements and home and community-based services programs.
- Knowledge of service authorizations, ADLs, IADLs, and person-centered care planning.
- Experience reviewing PCISPs, daily care logs, service records, or caregiver documentation.
- Familiarity with electronic medical record (EMR) or electronic health record (EHR) systems.
- Experience identifying compliance gaps, documenting audit findings, and coordinating corrective actions.
- Understanding of HIPAA and healthcare confidentiality requirements.
Key Competencies
- Attention to Detail: Ability to identify missing information, documentation inconsistencies, and potential compliance concerns.
- Analytical Thinking: Ability to evaluate records against established standards and recognize discrepancies.
- Organization: Ability to manage multiple audits, maintain accurate documentation, and meet deadlines.
- Communication: Ability to clearly communicate audit findings and required corrections.
- Confidentiality: Commitment to safeguarding client information.
- Accountability: Ability to follow established audit procedures and maintain consistent quality standards.
- Collaboration: Ability to work with administrative, care coordination, and management teams to support accurate documentation.
Position Expectations
The Audit Specialist is expected to complete assigned chart audits accurately and within established deadlines, maintain detailed records of findings, identify documentation deficiencies, and support timely resolution of identified issues.
Success in this position will be measured by audit accuracy, completeness of documentation reviews, timeliness of assigned audits, quality of findings, and adherence to company policies and applicable documentation requirements.
Equal Employment Opportunity
Elite Personal Care is committed to providing equal employment opportunities to all qualified applicants and employees without regard to any status protected by applicable federal, state, or local law.