Clinical Documentation Auditor – Educator

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

📋 Description

• Drive enhancements across the organization to elevate the quality, completeness, and accuracy of medical record documentation through comprehensive audit investigations, education, and data analysis.

• Identify patterns, trends, and opportunities for the entire Clinical Documentation Improvement (CDI) team across all acute care facilities to enhance accuracy and outcomes.

• Assist with large-scale retrospective audits upon request from hospital clients across the system, providing physician education when necessary.

• Review audits of case files and queries conducted by Clinical Documentation Specialists (CDIS) to ensure compliance and quality, utilizing developed audit tools.

• Monitor, analyze, and report audit findings for each Clinical Documentation Specialist (CDIS), Hospital Region, and System-wide to the Director and management team.

• Recognize knowledge gaps and deliver clear explanations and interpretations regarding any missing, unclear, conflicting, or non-compliant information captured by the CDIS.

• Research and remain updated on clinical and coding guidelines in quarterly Coding Clinics relevant to physician documentation improvement in an ICD-10 coding context.

• Support the overall quality, timeliness, and completeness of the health record to ensure accurate data, provider communication, and quality outcomes.

• Act as a resource for appropriate clinical documentation practices.

• Create presentation materials and provide training and education to physicians and CDIS staff as necessary to enhance documentation practices and ensure precise coding that reflects the severity of illness (SOI) and risk of mortality (ROM) for the patients served.

• Utilize audit tools to perform clinical quality audits.

• Develop and revise policies and procedures related to the CDIS audit function, collaborating with the Director and management team to refine audit tools as needed.

• Work together with leadership to perform targeted post-discharge documentation and coding audits as requested by hospital clients system-wide.

• Ensure the safety of patients, staff, and visitors while adhering to all Memorial Hermann policies, procedures, and standards within budgetary constraints, including time management, supply management, productivity, and quality of service.

• Foster individual professional growth and development by fulfilling mandatory and continuing education requirements and skills competency; support department goals that contribute to organizational success; serve as a preceptor, mentor, and resource for less experienced staff.

• Show commitment to caring for every community member by creating compassionate and personalized experiences.

• Exemplify Memorial Hermann’s service standards by delivering safe, caring, personalized, and efficient experiences to patients and colleagues.

⛳️ Requirements

• Bachelor’s degree in Nursing is required.

• A Master’s Degree in Nursing or Management is preferred.

• Current Texas state license or a temporary/compact license to practice professional nursing is essential.

• One of the following certifications is required: Certified Clinical Documentation Specialist (CCDS) from the Association of Clinical Documentation Improvement Specialists; Certified Clinical Documentation Integrity Professional (CDIP) from the American Health Information Management Association (AHIMA); or Certified Coding Specialist (CCS) from AHIMA.

• A minimum of three (3) years of Clinical Documentation Integrity (CDI) experience is required.

• Approved AHIMA ICD-10-CM/PCS Trainer is preferred.

• Previous experience in CDIS auditing and education, or a background in CDIS supervisory/management roles is preferred.

• Strong computer skills, including proficiency in MS Office (Word, Excel, Outlook) and familiarity with 3M Coding and Reimbursement software; experience with Epic EMR is preferred.

• Excellent communication, analytical, and problem-solving skills are crucial.

• Strong organizational abilities and attention to detail are necessary.

• Highly analytical with strong skills in risk assessment, impact analysis, and problem-solving.

• Self-motivated while also capable of being a collaborative team player and following direction.

• Must be flexible, able to multitask, and prioritize daily workloads, including performing concurrent chart reviews as needed.

🏝️ Benefits

• Exceptional experiences for every member of our community.