Clinical Documentation Auditor

Wellstar Health System • VIRTUAL-GA, GA

8d

About The Position

The Clinical Documentation Integrity (CDI) Auditor evaluates the quality and accuracy of clinical documentation in patient records and collaborates with the CDI team, providers, and coders to ensure records reflect patients’ clinical severity and level of service. The role audits provider documentation, CDI reviews, and coding accuracy; assesses CDI team performance; and identifies opportunities for improvement. It also provides feedback and education on documentation and coding practices to support clinical and operational excellence.

The auditor performs remote CDI and coding audits related to financial and quality metrics, including AHRQ metrics, PSI, HACs, HAI, and mortality. The role reviews records during admissions, identifies documentation opportunities, communicates with physicians, submits compliant electronic queries, follows up on responses, and escalates unanswered queries according to organizational processes. The auditor reconciles records in the Solventum/3M 360 Encompass CDI tool, maintains productivity metrics, participates in meetings, and supports regulatory compliance.

The position also supports stakeholder education, validation and special projects, CDI software and reporting accuracy, and the ongoing application of coding and billing rules. The auditor reviews Coding Clinic updates and applies relevant changes to processes. Other duties may be assigned, and the employee must comply with Wellstar policies, standards of work, and code of conduct.

Requirements

• Associate degree in Nursing, bachelor’s degree in Health Science, an accredited Health Science program, or a doctorate in Medicine.
• Minimum 2 years of experience working in an acute care setting as a Clinical Documentation Specialist (CDS).
• Minimum 5 years of healthcare experience.
• Obtain a Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) certification within 180 days of hire.
• Strong understanding of disease processes, clinical indications and treatments, provider documentation requirements, severity of illness, risk of mortality, and documentation supporting diagnoses and procedures for accurate coding and billing.
• Familiarity with an encoder and current working knowledge of Coding Clinic Guidelines and federal updates to the MS-DRG and APR-DRG systems.
• Experience in CDI/Coding chart review.
• Strong communication skills, tact, and effectiveness; ability to collaborate with medical staff, clinical departments, and facility leadership.
• Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives.
• Strong critical-thinking skills and ability to recommend and implement practical, efficient solutions.
• Proficient computer skills, including Microsoft Word, Excel, and PowerPoint, and CDI technology tools.
• Comfort with data analysis and preparing and maintaining records and written reports.
• Ability to drive effective use of CDI technology tools and reporting capabilities.
• Strong time management, training, and peer-development skills.
• Nurses must be licensed and uphold nursing practice standards set by the American Nurses Association.
• Non-clinical candidates with a coding background must hold at least one active/current certification upon hire: CCS, CPC, RHIA, or RHIT.

Nice To Haves

• Prior experience as a CDI/Coding auditor.
• Prior experience in inpatient case management or utilization review.
• Epic and Solventum/3M 360 Encompass experience.
• Preferred certifications or credentials: Registered Nurse (single-state or multistate compact), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).

Responsibilities

• Perform CDI and coding audits to improve financial and quality metrics, including AHRQ metrics, PSI, HAC, HAI, and mortality reviews.
• Prepare audit findings and support the CDI Education Lead with stakeholder education and provider education materials.
• Audit medical records to identify clinical documentation improvement opportunities and conduct real-time audits of reviews, queries, and reports.
• Provide feedback on CDI processes, query opportunities, query compliance, data trends, and areas for improvement.
• Perform validation and special-project tasks and ensure accurate, complete data entry and reporting in CDI software.
• Serve as a super user for CDI software and other applications used in the position.
• Review clinical documentation remotely during patient admissions and communicate documentation opportunities to physicians.
• Conduct hospital-wide medical record reviews to improve documentation quality, completeness, and accuracy and to support coding compliance, accurate reporting, and patient outcomes.
• Submit compliant electronic queries to clinicians and provide appropriate follow-up on queries.
• Escalate queries that are not answered timely to CDI leadership according to the Wellstar Query Escalation process.
• Coordinate query education needs with the CDI Education Lead and provide information needed to support education.
• Reconcile appropriate records daily in the Solventum/3M 360 Encompass CDI tool.
• Maintain required daily, weekly, and monthly metrics and meet productivity standards.
• Participate in departmental meetings, conference calls, and presentations and adhere to departmental policies and procedures.
• Support hospital compliance with federal and state regulatory requirements.
• Maintain knowledge of coding and billing rules and regulations and review quarterly Coding Clinic updates, applying required process changes.
• Perform other duties as assigned and comply with Wellstar policies, standards of work, and code of conduct.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree