Clinical Documentation & Improvement Quality Auditor & Trainer

Mercy Medical Center • Baltimore, MD

288d

About The Position

This position supports Mercy's philosophy of patient centered care by reviewing and ensuring the quality of Clinical Documentation Improvement (CDI) work performed by specialists, while also actively training and educating healthcare providers on proper documentation practices to improve the accuracy and completeness of medical records, aiming to optimize coding and reimbursement accuracy within the healthcare system; this often includes conducting audits, identifying areas for improvement, delivering training sessions, and collaborating with clinical teams to implement documentation changes.

Requirements

• Previous work experience as a Clinical Documentation Specialist is required.
• A bachelor's degree in nursing or a master's degree in nursing, or an equivalent combination of education in a related field and experience is required.
• Currently licensed to practice as a Registered Nurse in the state of Iowa required.
• Certified Clinical Documentation Specialist (CCDS) or equivalent certification required within 3 years of transfer or hire.

Nice To Haves

• Strong understanding of medical coding principles and ICD-10 guidelines.
• Excellent communication and presentation skills to effectively train healthcare providers.
• Analytical skills to identify trends and patterns in clinical documentation.
• Ability to work independently and as part of a team.

Responsibilities

• Conduct regular audits of CDI specialist case reviews to assess accuracy, completeness, and compliance with coding guidelines.
• Analyze audit findings to identify trends and areas for improvement in documentation practices.
• Provide feedback to CDI specialists on their performance and suggest corrective actions.
• Monitor key performance indicators (KPIs) related to CDI quality, such as query response rates and documentation improvement metrics.
• Develop and deliver comprehensive CDI training programs for healthcare providers, including physicians, nurses, and coding staff.
• Create educational materials and presentations based on current coding guidelines and clinical documentation standards.
• Conduct individual or group training sessions to address specific documentation concerns identified during audits.
• Provide ongoing support and mentorship to CDI specialists on complex cases and documentation challenges.
• Stay updated on the latest ICD-10 coding guidelines and clinical documentation requirements.
• Possess in-depth knowledge of medical terminology, disease processes, and clinical practices to effectively review patient records.
• Collaborate with clinicians to understand clinical nuances and ensure accurate documentation reflects the patient's condition.
• Work closely with CDI leadership to identify and implement strategies for improving documentation quality across the organization.
• Communicate findings and recommendations to healthcare providers and coding staff in a clear and constructive manner.
• Foster positive relationships with clinical teams to promote a culture of quality documentation.

Benefits

• Generous benefits package
• Growth opportunities
• Supportive team members

What This Job Offers

• Industry: Nursing and Residential Care Facilities
• Education Level: Bachelor's degree