Clinical Documentation Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct CDI and coding audits to enhance financial and AHRQ quality metrics

• Partner with the CDI Education Lead to develop educational materials for stakeholders and providers

• Execute reviews for staff, PSI, HAC, HAI, mortality, validation, and special projects

• Audit medical records to identify opportunities for clinical documentation improvement

• Carry out real-time audits of reviews, queries, and reports

• Analyze data and trends to pinpoint areas for improvement

• Offer feedback and education to CDI teams and coders regarding best practices in documentation and coding

• Review clinical documentation remotely during patient admissions

• Communicate documentation opportunities to physicians

• Conduct hospital-wide medical record reviews to enhance documentation quality, completeness, accuracy, coding compliance, reporting, and patient outcomes

• Submit compliant electronic queries to clinicians and provide necessary follow-up

• Escalate unresolved queries according to the Wellstar Query Escalation process

• Reconcile records daily using the Solventum/3M 360 Encompass CDI tool

• Maintain daily, weekly, and monthly metrics while meeting productivity standards

• Participate in departmental meetings, conference calls, and presentations

• Assist in ensuring hospital compliance with federal and state regulatory requirements

• Review quarterly updates from the Coding Clinic and adjust processes accordingly

• Keep abreast of coding and billing regulations to facilitate appropriate reimbursement

• Perform additional duties as assigned

⛳️ Requirements

• Associate's degree in Nursing, a bachelor's degree in Health Science, completion of an accredited Health Science program, or a doctorate in Medicine

• Clinical Documentation Specialist certification or Clinical Documentation Improvement Practitioner certification to be obtained within 180 days

• At least 2 years of experience working in an acute care setting as a Clinical Documentation Specialist

• Minimum of 5 years of healthcare experience

• Prior experience as a CDI/Coding auditor is preferred

• Previous inpatient case management or utilization review experience is preferred

• RNs must possess an active nursing license upon hire

• Non-clinical/coding candidates must hold at least one active/current certification upon hire: CCS, CPC, RHIA, or RHIT

• Strong understanding of disease processes, clinical indications, treatments, and provider documentation requirements

• Familiarity with an encoder and up-to-date knowledge of Coding Clinic Guidelines and federal DRG updates for MS and APR

• Experience in CDI/Coding chart review

• In-depth knowledge of Clinical Documentation Integrity, encompassing productivity, quality, education, training, compliance auditing, data analysis, trending, report management, and performance improvement

• Excellent communication, critical thinking, time management, training, and peer development skills

• Proficient in Microsoft Word, Excel, and PowerPoint

• Skilled in CDI technology tools and data analysis

• Ability to interpret, adjust, and apply guidelines, procedures, and continuous quality improvement initiatives

• Capability to collaborate effectively with medical staff, clinical departments, and facility leadership

• Proficient in preparing and maintaining records and written reports

• Experience with Epic and Solventum/3M 360 Encompass is preferred

🏝️ Benefits

• Full-time employment

• Remote work opportunities for clinical documentation reviews, audits, and related tasks

• Supportive work environment where contributions and ideas are appreciated

• Chance to serve with compassion, strive for excellence, and honor every voice

• Meaningful work focused on improving patient outcomes and healthcare quality

• Opportunities for professional education and development through stakeholder, CDI team, and coder education