CDI Auditor/Educator

UHS•Temecula, CA

1d•Hybrid

About The Position

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Auditor/Educator who will support staff development to ensure overall quality of work and completeness of clinical documentation reviews. This position is eligible for hybrid work schedule (onsite 3 days, remote 2 days). However, remote days are not guaranteed and subject to change based on department needs for in person training, education and site-based meetings. Duties include but not limited to: Providing audits for facilities based on data analytics, impact analysis, and provider performance to support educational direction for providers, leading to the most clinically accurate codeset to reflect patient’s stay while in the care of the facilities. Promote a partnership between CDI staff, Coding staff, Quality and Clinical Program staff, and providers. Provide education for accurate reimbursement with integrity, interacting with providers and staff to accurately represent Severity of Illness, Intensity of Service, Risk of mortality, Quality of Care, and Accurate Reporting for Clinical Programs. Utilize Official Coding Guidelines, AHA Coding Clinics, embedded CDI Software resources, and professional industry guidance to provide education as needed to CDI (Clinical Documentation Integrity) Team, Coders, and providers.Provide reviews of inpatient medical records for evaluation of utilization and documentation of acute care services to ensure appropriate provider documentation of diagnoses and care delivered. Provide cross-coverage in absence of CDI Staff, CDI Manager and/or RN CDI Lead. Position requires travel between sites throughout the Southern California region to support team collaboration, education, and training efforts.

Requirements

Associate's degree from an accredited College or University in the field of nursing required.
Minimum of five (5) years clinical experience in acute care setting (Critical care, Medical/Surgical or Emergency Medicine) plus 3-5 years in inpatient acute care setting CDI experience required.
Current license as a Registered Nurse in the State of California required.
Current certification(s) for Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required.
Demonstrates knowledge and ensures compliance with The Joint Commission and Title 22 standards and guidelines.
Demonstrates compliance with Healthcare policies and procedures at all times.
Ability to set priorities and appropriately organize workload and complete assignments in a timely manner.
Familiarity with basic medical laws and ethics, i.e. consents, confidentiality.
Knowledge of emergency procedures, medical terminology and medical abbreviations.
Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public.
Must have knowledge of PC and applications.
Ability to work independently in a time oriented environment is essential.
Working knowledge of current ICD-10-CM coding guidelines, with working knowledge of Medicare reimbursement system required.
Working knowledge of inpatient admission criteria.
Detailed oriented, ability to collect, trend and report data.
Excellent organizational skills required.

Nice To Haves

Bachelor's degree from an accredited College or University in the field of nursing preferred.
Minimum of five (5) experience in CDI Leadership and/or CDI Education strongly preferred.
Dual certification CCDS and CDIP strongly preferred.
Dual certification with credentials of CCDS, CDIP, CCDS-O, CCS, RHIT preferred.

Responsibilities

Providing audits for facilities based on data analytics, impact analysis, and provider performance to support educational direction for providers, leading to the most clinically accurate codeset to reflect patient’s stay while in the care of the facilities.
Promote a partnership between CDI staff, Coding staff, Quality and Clinical Program staff, and providers.
Provide education for accurate reimbursement with integrity, interacting with providers and staff to accurately represent Severity of Illness, Intensity of Service, Risk of mortality, Quality of Care, and Accurate Reporting for Clinical Programs.
Utilize Official Coding Guidelines, AHA Coding Clinics, embedded CDI Software resources, and professional industry guidance to provide education as needed to CDI (Clinical Documentation Integrity) Team, Coders, and providers.
Provide reviews of inpatient medical records for evaluation of utilization and documentation of acute care services to ensure appropriate provider documentation of diagnoses and care delivered.
Provide cross-coverage in absence of CDI Staff, CDI Manager and/or RN CDI Lead.
Position requires travel between sites throughout the Southern California region to support team collaboration, education, and training efforts.