Clinical Documentation Audit Specialist

About the role

The Clinical Documentation Audit Specialist supports Jefferson's goal of ensuring accurate quality data reporting and providing educational feedback to CDI managers. This role involves expert-level CDI reviews of targeted medical records, participating in enterprise-wide performance improvement efforts, and collaborating with providers to improve clinical documentation.

Responsibilities

• Accurately reviews designated medical records for completeness in documenting diagnostic and procedural information in compliance with CMS, Department of Health regulatory, and financial requirements.
• Provides expert level review of targeted medical records to ensure accurate data capture of patient diagnoses and procedures.
• Performs second level reviews on designated records (e.g., mortality, Patient Safety Indicator reviews, sepsis, etc.) to ensure accurate quality reporting and serves as department liaison for quality related meetings.
• Prepares well-written and compliant queries to communicate with physicians and other providers regarding clarifying conflicting, missing, or incomplete documentation in the medical record.
• Supports revenue cycle initiatives by supporting timely CDI query follow-up in accordance with query escalation process.
• Collaborates with management to utilize expert level CDI skills to conduct quarterly quality record review audits of CDI specialists across the enterprise.
• Assists with enterprise-wide documentation improvement quality initiatives.
• Evaluates opportunities for CDI education and/or CDI workflow and process improvements.
• Participates on hospital committees to conduct record review studies, as necessary, to facilitate improvement in clinical documentation processes to ensure overall quality, completeness, and compliance.

Requirements

Strong working knowledge and experience in clinical record reviews, 3M encoder coding systems, Diagnostic Related Group (DRG) system, and Epic EHR system required. Expert level working knowledge of ICD-10 diagnosis and procedural coding conventions and severity of illness/risk of mortality required. Excellent interpersonal and communication skills (both written and verbal) with previous experience working collaboratively within teams required. Prior data analytic skills and understanding case mix index and DRG/all patient refined (APR) diagnosis related group systems. Strong working knowledge of Microsoft Office; Outlook, Word, Excel, PowerPoint. Prior exposure to quality record reviews (i.e. Patient safety indicators, mortality) preferred. BSN, PA or medical graduate degree preferred. Experience with hospital acquired conditions, patient safety indicators, and risk adjustment methodology (specifically Vizient, Elixhauser, or Hierarchical Condition Category) preferred. Prior presentation and educational training skills preferred. Successful completion of Vizient Risk Adjustment Training.

Qualifications

Minimum one year experience required as a CDI specialist. Minimum of two years hands-on clinical experience either obtained through inpatient clinical nursing (i.e. RN, BSN), medical school, or residency or 5 years acute care inpatient medical coding. Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certifications required or within six months of eligibility.