Clinical Documentation Auditor, Educator

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

📋 Description

• Evaluate the precision, consistency, and adherence of clinical documentation reviews conducted by front-line Clinical Documentation Specialists (CDS).

• Facilitate the professional growth of the Clinical Documentation Improvement (CDI) team.

• Provide educational support to providers aimed at enhancing clinical documentation practices.

• Conduct regular and on-demand audits of CDI queries, documentation assessments, and electronic health record (EHR) entries.

• Assess the suitability of queries, clinical evidence, and conformity with coding regulations (ICD-10-CM/PCS, UHDDS, CMS).

• Manage internal audit tools and monitor performance metrics.

• Regularly present audit results to leadership.

• Design and implement extensive CDI education programs.

• Develop and update educational resources, tip sheets, and query templates.

• Provide focused documentation training to providers through presentations, personalized feedback, and coaching on query responses.

⛳️ Requirements

• Clinical Documentation Professional credential from the Association of Clinical Documentation Improvement Specialists obtained before the hire date or job transfer date.

• Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS).

• High School diploma equivalency with 2 years of cumulative experience OR an Associate's degree/Bachelor's degree OR 4 years of relevant cumulative job-specific experience.

• Advanced knowledge of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.

• In-depth understanding of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.

• Demonstrated ability to create engaging educational content tailored to various audiences (clinical, coding, administrative).

• Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).

🏝️ Benefits

• Paid time off (PTO).

• Various health insurance options and wellness plans.

• Retirement benefits, including employer matching plans.

• Long-term and short-term disability coverage.

• Employee assistance programs (EAP).

• Parental leave and adoption assistance.

• Tuition reimbursement.

• Opportunities to contribute to your community.