Clinical Documentation Specialist – Audit and Education

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 frontline Clinical Documentation Specialists (CDS).

• Foster the professional growth of the Clinical Documentation Improvement (CDI) team and deliver educational sessions for providers to enhance clinical documentation practices.

• Conduct regular and on-demand audits of CDI queries, documentation assessments, and electronic health record (EHR) entries to ensure compliance with internal standards, industry guidelines, and regulatory mandates.

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

• Detect trends, discrepancies, and areas for enhancement in the performance of the CDI team.

• Maintain internal auditing tools, monitor performance metrics, and routinely present insights to leadership.

• Offer personalized coaching for new or developing team members based on audit results or performance patterns.

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

⛳️ Requirements

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

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

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

• In-depth knowledge of CDI best practices, Diagnosis-Related Group (DRG) methodologies (MS-DRG and APR-DRG), and coding principles.

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

• A Texas RN license is highly preferred.

• Strong understanding of Severity of Illness/Relative Outcome Model (SOI/ROM), Major Complications/Comorbidities (MCC/CC) capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.

🏝️ 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, and more.