Clinical Documentation Auditor

Job Description

Responsible for facilitating and obtaining quality physician documentation for clinical conditions or procedures to support the severity of illness, expected risk of mortality, and complexity of patient care. This position educates the patient care team on documentation guidelines, including physicians, allied health practitioners, nursing, care management, and quality abstracters. Additionally, this role ensures adherence to departmental and organizational goals, objectives, standards of performance, and policies and procedures. In addition, this position continually ensures quality documentation and regulatory compliance.

Actively participates in maintaining respectful relationships with all team members. Completes accurate and timely record reviews to ensure the integrity of documentation compliance. Inputs data accurately and concisely into CDI Software. Reviews concurrent and retrospective medical records for documentation compliance, including completeness and accuracy for SOI, ROM, and quality. Supports CDI documentation strategies and educates self and team members through monthly mandated education sessions and provided educational tools. Conducts quality audits, including deceased second-level reviews, focused disease process reviews, patient safety indicators, and CDI team audits. Collects, analyzes, and reports data to the CDI Leadership team. Recognizes opportunities for documentation improvement using strong critical-thinking skills.

Education

Bachelor's [Required] Master's [Preferred]

Work Experience

• 1+ of second level review CDIS experience [Preferred]
• 4+ of recent clinical documentation specialist experience [Required]
• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• 5+ CDI experience [Preferred]

Licenses And Certifications

CCDS (Certified Clinical Documentation Specialist) certification and 2 years Clinical Documentation Integrity experience Required

Physical Requirements

View physical requirements

Pay Range

$66,170.74 - $123,073.07