Clinical Documentation Integrity Auditor

About the role

Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.

Responsibilities

• Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.
• Performs routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
• Evaluates query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).
• Identifies trends, variances, and opportunities for improvement in CDI team performance. Maintains internal audit tools, tracks performance metrics, and presents findings to leadership on a regular basis.
• Provides one-on-one coaching for new or developing team members, based on audit findings or performance trends.
• Creates and maintains educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.

Requirements

• Licensure / Certification / Registration: Required Credential(s) Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
• Education: High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Preferences

• Must have a Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS).
• Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.
• Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
• Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).

Pay

$96,208.99 - $134,109.89

Schedule

Full Time | Days | Monday-Friday