Clinical Documentation Specialist – Audit and Education

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

📋 Description

• Conduct routine and ad hoc audits of CDI queries, documentation assessments, and EHR entries to ensure compliance with internal standards, industry guidelines, and regulatory requirements.

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

• Manage internal audit tools effectively.

• Monitor performance metrics consistently.

• Regularly present audit findings to leadership.

• Design and implement comprehensive CDI education programs.

• Develop and update educational materials, tip sheets, and query templates in line with evolving CDI best practices.

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

⛳️ Requirements

• Credentialed as a Clinical Documentation Professional by the Association of Clinical Documentation Improvement Specialists, obtained prior to the hire date or job transfer date.

• High School diploma or equivalent with 2 years of cumulative experience, OR an Associate's or Bachelor's degree, OR 4 years of relevant cumulative job-specific experience required.

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

• In-depth understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.

• Strong knowledge 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 varied audiences (clinical, coding, administrative).

• Proficient with audit tools, EHR systems (such as Epic), and CDI software platforms (including Iodine, 3M, Nuance).

🏝️ Benefits

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options.

• Employer-matched 403(b).

• Planning and hardship resources.

• Disability and life insurance.

• Pro-rated paid time off (PTO) and holidays.

• Ascension-paid tuition (Vocare).

• Reimbursement.

• Ongoing professional development and online learning.

• Employee Assistance Program.

• Counseling and peer support.

• Spiritual care and stress management resources.

• Parental leave.

• Adoption assistance and family benefits.

• Optional legal and pet insurance.

• Transportation savings.