Clinical Documentation Auditor

Job Description: Clinical Documentation Auditor - CHHA

Department: Compliance / Clinical Review / Care Standards

Reports To: VP of Clinical Operations

Position Summary

The Clinical Documentation Auditor is responsible for reviewing clinical documentation across patient charts to ensure accuracy, completeness, and compliance with regulatory, payer, and agency standards. The auditor provides feedback to clinicians and leadership, helps identify documentation trends, and supports ongoing quality improvement initiatives within the Certified Home Health Agency (CHHA).

Key Responsibilities

• Perform routine and focused audits of patient charts for:
  - Timely completion of Start of Care (SOC), Recertification, and Discharge OASIS
  - Visit documentation (nursing, therapy, aide)
  - Plan of Care compliance
  - MD order management and signed/verbal order tracking
  - Medication reconciliation
  - Visit frequency adherence
  - Missed visit documentation and follow-up
  - Care coordination and patient goals documentation
  - Assessment of comorbid conditions, safety, and environment
• Verify that documentation supports medical necessity, homebound status, and meets payer requirements (including Medicare).
• Identify gaps, trends, or inconsistencies in documentation and escalate as appropriate.
• Collaborate with clinical leadership to provide feedback and education to field staff.
• Assist in preparing for surveys and audits by regulatory or accrediting bodies.
• Participate in development and updating of internal audit tools and workflows.
• Maintain up-to-date knowledge of CHHA regulations, Medicare Conditions of Participation, and payer documentation requirements.