Shift Audit RN

Responsibilities

Review 100% of skilled-nursing shifts from the prior week. Verify nursing documentation is complete and clinically appropriate: assessments, vitals, medication administration, G-tube/feeding documentation, flushes, respiratory treatments, oxygen, seizure documentation, I&O, interventions, etc., as applicable to each patient's orders. Compare documentation against the physician orders/plan of care, rather than simply checking whether fields were completed.

Identify missing, inconsistent, late, or clinically questionable documentation. Verify the nurse's shift time and documentation support the services being submitted for billing. Do not approve/sign off a deficient shift simply to clear it from the system.

Contact the nurse directly when corrections or clarification are required and follow the issue through to resolution. Escalate medication errors, missed treatments, significant changes in condition, or other clinical concerns according to your agency's policies. Complete the authorized RN review/sign-off after deficiencies have been resolved.

Maintain a weekly audit/exception log so you can identify nurses with repeated documentation problems.

Job Details

Flat Rate of $300 per week Approximately 20 nursing records per week to review and approve, requiring an estimated 4-6 hours per week. Must be available to commit to a consistent day each week for initial shadowing and training. Once training is complete, must participate in a weekly Zoom meeting to review documentation concerns, outstanding issues, and any necessary follow-up.

Knowledge, Skills & Abilities Required

Able to demonstrate basic understanding and Proficiency of workplace software Able to effectively communicate in English with all levels of the workforce, both clinical and non-clinical. Able to perform and prioritize multiple functions or tasks.

Minimum Education & Experience

Requirements

• Bachelor’s degree in Nursing
• Current Georgia Registered Nurse (RN) license
• 1+ year of medical supervision experience
• Home healthcare experience *nice to have*