Note: The job is a remote job and is open to candidates in USA. Professional is seeking a Clinical Documentation Integrity Auditor to evaluate the quality, accuracy, completeness, and compliance of clinical documentation. The role involves performing audits of medical records and partnering with various healthcare professionals to enhance documentation practices and support quality improvement initiatives.
Responsibilities
- Perform audits of CDI reviews, medical records, and provider queries to evaluate the accuracy, completeness, and consistency of CDI specialists' work
- Assess CDI specialists' documentation review practices, query opportunities, and compliance with organizational policies and industry standards
- Provide individualized coaching, mentoring, and education to CDI Specialists based on audit findings to improve clinical judgment, documentation review techniques, query writing, and overall performance
- Serve as the CDI department's subject matter expert by educating staff on MS-DRGs, APR-DRGs, ICD-10-CM/PCS, Severity of Illness (SOI), Risk of Mortality (ROM), clinical validation, and compliant physician query practices
- Evaluate provider queries for clinical accuracy, compliance, and effectiveness, ensuring adherence to AHIMA, ACDIS, and organizational guidelines
- Validate accurate capture of diagnoses, procedures, CCs, MCCs, and other documentation impacting reimbursement, quality measures, and regulatory reporting
- Maintain current knowledge of CMS regulations, coding guidelines, CDI best practices, and emerging industry trends to ensure the CDI program remains compliant and effective
Skills
- Minimum of five (5) years of Clinical Documentation Improvement (CDI) experience in a large acute care hospital setting
- Minimum of three (3) years conducting CDI quality reviews, audits, or performance improvement initiatives
- Strong knowledge of ICD-10-CM/PCS
- Strong knowledge of MS-DRG and APR-DRG methodologies
- Strong knowledge of Severity of Illness (SOI) and Risk of Mortality (ROM)
- Strong knowledge of Compliant Query Writing
- Strong knowledge of Hospital-Acquired Conditions (HACs)
- Strong knowledge of Clinical validation principles
- Strong knowledge of CMS regulations
- Strong knowledge of Documentation compliance standards
- Experience reviewing concurrent and retrospective CDI cases
- Strong analytical, critical thinking, and problem-solving skills
- Excellent written and verbal communication skills
- Ability to educate CDI specialists, coders, and operational leadership
- Proficiency with Electronic Health Records (EHRs), CDI software, Microsoft Excel, and reporting tools
- Bachelor's degree in Health Information Management, Nursing, or a related field
- Minimum of 3 years of experience in clinical documentation improvement or a similar role in a healthcare setting
- Demonstrated experience working with electronic health records (EHR) systems
- Proven track record of collaborating with healthcare professionals to enhance documentation quality
- Strong understanding of medical terminology, coding systems (such as ICD-10, CPT), and healthcare regulations
- Excellent analytical skills with the ability to interpret complex clinical data
- Proficient in using clinical documentation software and tools
- Exceptional communication and interpersonal skills to effectively interact with medical staff and administrative personnel
- Ability to conduct training sessions and provide guidance to healthcare providers on documentation best practices
- Detail-oriented with strong organizational skills to manage multiple projects and deadlines efficiently
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Certified Coding Specialist (CCS)
- Certified Professional Coder (CPC)
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
Benefits
- Full-time, Part-time & PRN positions
- Health Insurance (medical, dental, vision), Flexible Spending Account, & Aflac Group Products
- Volunteer ReachOut Program: 40 Hours of Paid Time to Volunteer
- 401(k)/Roth with Company Match
- Healthy Work-Life Balance
- Collaborative Work Environment
- Flexible Work Schedule
- PTO for Full & Part-Time Employees
- Employee Incentive Reward Program
- Annual Stipend for Professional Certifications and Memberships *(for Medical Coding Employees)*
Company Overview