Clinical Documentation Auditor

1000 Wellstar Health System, Inc. • Atlanta, GA

9d

About The Position

The Clinical Documentation Integrity (CDI) Auditor evaluates the quality and accuracy of clinical documentation in patient records and works with the CDI team, providers, and coders to ensure records reflect patients’ clinical severity and level of service. The auditor also evaluates CDI team performance, identifies improvement opportunities, and provides feedback and education on documentation and coding best practices to support clinical and operational excellence.

The role performs CDI and coding audits to improve financial and quality metrics, including AHRQ measures, and collaborates with the CDI Education Lead on stakeholder education. It conducts medical-record reviews, real-time audits of reviews and queries, validation and special-project work, and analysis of data and trends. The auditor reviews documentation remotely during admissions, identifies opportunities to improve physician documentation, communicates those opportunities to physicians, submits and follows up on compliant electronic queries, and escalates unanswered queries as required. The position also reconciles records in the Solventum/3M 360 Encompass CDI tool, maintains productivity metrics, participates in meetings and presentations, supports regulatory compliance, and keeps current with coding and billing rules and updates.

Requirements

• Associate degree in Nursing, bachelor’s degree in Health Science, an accredited Health Science program, or doctorate in Medicine.
• At least 2 years of experience working in an acute-care setting as a Clinical Documentation Specialist (CDS).
• At least 5 years of healthcare experience.
• Certification as a Clinical Documentation Specialist or Clinical Documentation Improvement Practitioner within 180 days of hire.
• For candidates with a non-clinical coding background, at least one active/current certification upon hire: CCS, CPC, RHIA, or RHIT.
• Strong understanding of disease processes, clinical indications and treatments, and provider documentation requirements to reflect severity of illness and risk of mortality and support 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.
• Expert knowledge or experience managing CDI functions, including productivity, quality, education and training, compliance auditing, data analysis and trending, report management, and performance-improvement initiatives.
• CDI/coding chart-review experience.
• Excellent communication skills, using tact and effectiveness, and 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 the CDI technology tools needed for the role.
• Comfort with data analysis and preparing and maintaining records and written reports.
• Ability to promote effective use of CDI technology tools and reporting capabilities.
• Strong time-management, training, and peer-development skills.
• RNs must be licensed and uphold the nursing Scope of Practice and Code of Ethics standards established by the American Nurses Association.

Nice To Haves

• Prior experience as a CDI/coding auditor.
• Prior experience in inpatient case management or utilization review.
• Epic experience.
• Solventum/3M 360 Encompass experience.
• Preferred RN license (single-state or multi-state compact).
• Preferred coding or health-information credentials: CCS, CPC, RHIA, or RHIT.

Responsibilities

• Perform CDI and coding audits to improve financial and quality metrics, including AHRQ measures.
• Collaborate with the CDI Education Lead to prepare and provide stakeholder education, including gathering materials and preparing presentations.
• Conduct assigned staff, PSI, HAC, HAI, mortality, and other reviews remotely.
• Audit medical records to identify opportunities related to clinical documentation improvement, PSI, HACs, mortality, and related areas.
• Conduct real-time audits of reviews, queries, and reports; provide feedback on processes, query opportunities, and query compliance.
• Review data and trends to identify further opportunities for improvement.
• Perform validation and special-project tasks to support CDI leadership and ensure accurate, complete data in CDI software.
• Serve as a super user for CDI software and other applications used in the role.
• Review clinical documentation remotely during patient admissions and communicate opportunities for improving physician documentation.
• Perform hospital-wide medical-record reviews to improve documentation quality, completeness, and accuracy and support coding compliance, accurate reporting, and patient outcomes.
• Submit electronic queries to clinicians when appropriate, ensuring records are complete and accurate for coding after discharge.
• Ensure queries are compliant, grammatically correct, concise, error-free, and consistent with organizational policies and procedures.
• Follow up on queries and immediately escalate queries that are not answered timely to CDI leadership under the established escalation process.
• Refer query-related education needs to the CDI Education Lead and provide the 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; adhere to departmental policies and procedures.
• Help assure hospital compliance with federal and state regulatory requirements.
• Maintain knowledge of coding and billing rules and regulations and review quarterly Coding Clinic changes and summaries.
• Perform other duties as assigned and comply with Wellstar Health System policies, standards of work, and code of conduct.

What This Job Offers

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