Clinical Documentation Specialist, Audit Coordinator

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

📋 Description

• Delivers onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI initiatives as part of the System Office CDI Float Pool.

• Applies advanced coding and clinical expertise to enhance the quality and integrity of clinical documentation.

• Responsible for reviewing and auditing medical record clinical documentation to verify medical necessity, severity of illness, risk of mortality, precise coding, clinical evidence, resources utilized, and levels of service provided to all patients.

• Conducts audits on HM Clinical Documentation Specialists (CDSs) for query compliance, workflow, and identification of missed documentation opportunities.

• Educates end users on the CDI system software, standards, and workflow processes.

• Exhibits a thorough understanding of clinical documentation to ensure that medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and service levels are appropriately documented in health records.

• Performs clinical documentation chart reviews and queries providers as necessary to meet the staffing needs of RHMs.

• Reviews can take place either onsite or remotely.

• Adheres to HM CDI Program workflows and processes while coordinating with the local CDI Team to support operational functions.

• Engages with physicians and other healthcare team members at HM concerning clinical documentation as part of local CDI Team responsibilities.

• Reviews medical records, queries, assigned codes from CDS and coders, CDI software entries, etc., upon request to supply feedback to HMs for areas of improvement.

• Provides training to end users on CDI system software, standards, and workflows.

• Offers documentation education to providers and healthcare team members at RHM as part of CDI Team responsibilities or upon request.

• Demonstrates a capacity to swiftly learn and master various CDI technology applications, systems, and workflows utilized across the organization.

• Offers expertise in problem-solving based on theoretical knowledge, clinical experience, and sound judgment, while serving as a professional role model through exemplary practice behaviors.

• Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system, including data collection and maintenance of the CDI Dashboard.

• May create educational content for providers and CDSs regarding CDI workflows and processes, CDI and Physician software systems, as well as documentation and coding guidelines upon request.

• Performs additional duties as assigned by leadership.

⛳️ Requirements

• Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) Certification as a Clinical Documentation Specialist (CCDS), or Certified Documentation Improvement Professional (CDIP) is preferred.

• Experience in Clinical Documentation Integrity is essential.

• Exceptional communication (both verbal and written), interpersonal, collaboration, and relationship-building abilities.

• Strong critical thinking skills and capability to integrate knowledge effectively.

• Required prioritization and organizational skills.

• Ability to educate all healthcare team members on clinical documentation matters.

• Experience with databases, spreadsheet software, and presentation software is preferred.

• Must be comfortable working independently within a collaborative, shared leadership environment.

• Must exhibit a personal presence characterized by honesty, integrity, and compassion, with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

🏝️ Benefits

• Comprehensive health coverage options.

• Retirement savings plan with employer matching.

• Professional development opportunities and continuing education support.

• Work-life balance initiatives.