Healthcare Documentation Quality Assurance
Remote•United States•Full-time
$18 hourly
$18 hourly
About the Job
Position Summary:
The EHR Documentation Quality Specialist reviews patient records to ensure that documentation is accurately and completely entered into the electronic health record (EHR). This role focuses on verifying that information is placed in the correct location, required documentation is present, and records follow established documentation guidelines.
This is a documentation review role and does not involve providing clinical care or evaluating clinical decision-making.
Essential Functions:
- Review EHR records to ensure documentation is complete and accurately entered.
- Verify that information is documented in the correct sections, templates, and fields within the EHR.
- Identify missing, incomplete, or incorrectly entered documentation.
- Document and track errors and recurring documentation issues.
- Provide clear feedback regarding documentation corrections and trends.
- Escalate recurring or significant documentation issues to the appropriate team member or manager.
- Maintain accurate QA tracking logs and reports.
- Follow established documentation standards, processes, and HIPAA requirements.
- Support efforts to improve the accuracy and consistency of EHR documentation.
- Basic knowledge of healthcare and medical terminology.
Ideal Candidate:
- Strong attention to detail and accuracy.
- Comfortable reviewing electronic records and identifying errors or missing information.
- Organized and able to follow established processes and guidelines.
- Comfortable working with repetitive, detail-oriented tasks.
- Basic experience with EHR systems, data entry, or documentation review is preferred.
- Healthcare experience is helpful but not required.
- This role does not require clinical licensure and is not responsible for evaluating patient care or clinical decision-making.