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Full Time Rn Medical Record Review Jobs (NOW HIRING)

CommonSpirit Health

RN II Telemetry 2S

Oxnard, CA · On-site

$2.1K - $2.9K/wk

Feedback, Medical Record Review, Observation. * Advance Directives: Consistently and accurately ... Registered Nurse: CA RN, upon hire * Basic Life Support - BLS, upon hire * Advanced Cardiac Life ...

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How much do full time rn medical record review jobs pay per hour?

As of Sep 5, 2026, the average hourly pay for full time rn medical record review in the United States is $44.91, according to ZipRecruiter salary data. Most workers in this role earn between $34.38 and $53.37 per hour, depending on experience, location, and employer.

What does a full time RN medical record review do?

A Full Time RN Medical Record Review is a registered nurse who specializes in reviewing patient medical records to ensure accuracy, compliance, and quality of care. Their responsibilities often include examining documentation for completeness, verifying that treatments and diagnoses are properly recorded, and making recommendations for improvements. They may also work with healthcare providers to clarify documentation and help ensure the facility meets regulatory standards. This role is crucial in supporting healthcare quality assurance, risk management, and reimbursement processes. The position typically requires an active RN license and experience in clinical nursing or health information management.

What are the key skills and qualifications needed to thrive as a full time RN medical record review, and why are they important?

To thrive as a Full Time RN Medical Record Review, you need a current RN license, strong clinical knowledge, and thorough understanding of medical documentation and healthcare regulations. Familiarity with electronic health record (EHR) systems, coding standards (such as ICD-10 and CPT), and relevant compliance certifications like HIPAA is typically required. Attention to detail, analytical thinking, and effective written communication are crucial soft skills for accurately reviewing records and providing clear reports. These competencies ensure that patient records are accurate, regulatory standards are met, and quality of care is consistently monitored.

What are some common challenges full time RNs face when conducting medical record reviews, and how can they overcome them?

Full Time RNs in medical record review often encounter challenges such as incomplete or inconsistent documentation, navigating different electronic health record (EHR) systems, and balancing accuracy with productivity requirements. To overcome these obstacles, it's important to develop strong attention to detail, stay updated on documentation standards, and communicate effectively with clinical staff to clarify ambiguities. Additionally, collaborating with team members and participating in ongoing training can help RNs adapt to evolving compliance regulations and streamline the review process.

What is the difference between Full Time Rn Medical Record Review vs Full Time Rn Case Manager?

AspectFull Time Rn Medical Record ReviewFull Time Rn Case Manager
CertificationsRN license, possibly specialized certificationsRN license, case management certification often preferred
Work EnvironmentReviewing medical records, often remote or office-basedCoordinating patient care, often in clinical or office settings
Employer & IndustryInsurance companies, healthcare providers, legal firmsHospitals, insurance companies, healthcare organizations

Full Time Rn Medical Record Review involves analyzing medical records for accuracy, compliance, or legal purposes, primarily working with documentation. Full Time Rn Case Managers focus on coordinating patient care, discharge planning, and communication with healthcare providers. While both roles require RN licensure, their daily tasks and work environments differ significantly.

What cities are hiring for Full Time Rn Medical Record Review jobs?

Cities with the most Full Time Rn Medical Record Review job openings:

What are the most commonly searched types of Rn Medical Record Review jobs?

The most popular types of Rn Medical Record Review jobs are:

What states have the most Full Time Rn Medical Record Review jobs?

States with the most job openings for Full Time Rn Medical Record Review jobs include:

Full Time Rn Medical Record Review jobs near you

Medical Record Reviewer

Community Home Health Care & CIHC

Fort Wayne, IN

Full-time

Re-posted 29 days ago

Job description

Medical Record Reviewer

Community Home Health Care is hiring an in-office QA Nurse to oversee the accuracy, completeness, and regulatory compliance of all clinical documentation. This role is essential to ensuring our client records meet professional standards and support safe, high-quality care.

What You’ll Do

Clinical Record Audits & Documentation Review

  • Perform monthly audits of skilled nursing notes for all visiting nurses.
  • Provide direct, timely feedback to nurses on missing or incorrect documentation.
  • Re-audit records when deficiencies continue and notify the Clinical Manager as needed.
  • Audit OASIS assessments (SOC, ROC, Recertification, and Follow-Up) prior to transmission.
  • Audit at least 10% of each RN Case Manager’s charts monthly, focusing on recerts, SOC, and ROC visits.
  • Audit all documentation for newly hired RN Case Managers during their probation period.
  • Complete discharge record reviews and notify RN Case Managers when discharge charts need QA review.

Deficiency Identification & Follow-Up

  • Review charts for accuracy, completion, legal compliance, and proper care documentation.
  • Document deficiencies on the Case Conference Review form.
  • Notify nurses and department staff of deficiencies and required corrections.
  • Conduct discharge analysis when clients leave the agency.

Reporting & Collaboration

  • Track patterns and trends in documentation issues.
  • Communicate concerns and recurring problems to the Clinical Manager.
  • Support corrective action steps when needed.
  • Compile a quarterly audit report summarizing the previous three months.
  • Assist with ongoing chart review processes as assigned.

What We’re Looking For

  • Active RN license in the State of Indiana.
  • Strong understanding of home health documentation standards, Medicare/Medicaid requirements, and OASIS.
  • Excellent attention to detail and strong organizational skills.
  • Ability to communicate clearly, professionally, and constructively with nursing staff.
  • Comfortable working fully in-office in a fast-paced environment.
  • Previous QA or chart auditing experience preferred, but strong clinical documentation skills will also be considered.

Schedule & Work Environment

  • Monday–Friday schedule, in-office at the Fort Wayne location.
  • Works closely with the Clinical Manager, RN Case Managers, and field staff.
  • Computer-based role with consistent chart auditing and record review responsibilities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws. We are committed to creating a diverse and inclusive workplace for all employees.

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