Clinical Documentation Auditor

Wellstar Health System

1d • Remote

About The Position

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives. Work Shift Job Summary: The Clinical Documentation Integrity (CDI) Auditor must be good at problem-solving, clinical and coding knowledge, and communicating and collaborating. The CDI Auditor evaluates the quality and accuracy of the clinical documentation in the patient record, and works with the CDI team, providers, and coders to make sure the record shows the patient's clinical severity and level of service. The CDI auditor also looks at the performance of the CDI team and finds areas to improve. CDI auditor audits provider documentation, CDI and coding accuracy to confirm or find ways to improve proper documentation. CDI auditor gives feedback and education to the CDI team and coders on documentation and coding best practices and helps the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.

Requirements

• Associates Nursing or Bachelors Health Science or Accredited Program Health Science or Doctorate Medicine
• Cert Clin Document Specialist within 180 Days or Cert Document Improvement Prac within 180 Days
• Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof Coder-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred
• It is expected that all RNs are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required or It is expected that all non-clinical (coding) background candidates have at least one of the following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or (4) Registered Health Information Technician (RHIT) from AHIMA Upon Hire Required
• Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required
• Minimum 5 years healthcare experience Required
• Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors
• Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
• Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives
• CDI/Coding chart review experience required
• Excellent communication skills, employing tact and effectiveness
• Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members
• Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
• Excellent critical thinking skills, with the ability to recommend and implement practical and efficient solutions
• Must have proficient computer skills in Microsoft Apps, such as Word, Excel, and PowerPoint, as well as CDI technology tools required for the job functions
• Must be comfortable with doing data analysis, and preparing and maintaining records and written reports
• Drives optimal use of the CDI technology tool and reporting capabilities
• Excellent time management, training, and peer development skills

Nice To Haves

• Prior experience of working as a CDI/Coding auditor is preferred
• Prior experience of working in inpatient case management or utilization review is preferred
• Epic and Solventum/3M 360 Encompass experience is preferred

Responsibilities

• Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, and collaboration with CDI Education Lead to ensure stakeholder education. Assists CDI Education Lead remotely with preparing provider education materials, gathering articles or other information for presentations and meetings. Performs staff, PSI, HAC, HAI, mortality, etc. reviews remotely as assigned by the management.
• Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician.
• Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.

What This Job Offers

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