Clinical Documentation Integrity (CDI) Auditor

Cook Children's Health Care System • Fort Worth, TX

1d • Onsite

About The Position

The Clinical Documentation Integrity Auditor reviews patient charts for documentation accuracy and specificity, coding accuracy, and APR-DRG assignment compliance. The role evaluates documentation after coding and before billing, assigns codes as needed, and verifies that Present on Admission status and DRGs are accurate and supported by documentation and compliance requirements. The auditor conducts pre-bill audits, tracks and reports audit results, reviews payer coding denials, and provides feedback and education to providers and coders on documentation improvement opportunities.

The position also reviews concurrent admissions and prepares documentation clarification queries for providers. It serves as a liaison among coding staff, Physician Advisors, and providers, and communicates with and educates these groups about documentation improvement. The auditor reports results to appropriate individuals, groups, and committees monthly or as requested, and builds working relationships across disciplines. The role requires current knowledge of clinical documentation improvement, Epic systems, coding schemes, APR-DRG groupers, Cook Children’s policies and procedures, and applicable regulatory requirements and guidelines for documentation, coding, billing, and reimbursement. The role may assist in setting goals and priorities for the coding team.

Requirements

• Associate degree in Business or a clinical field, such as Nursing or Health Information Management.
• For coding professionals: at least three years of current and continuous acute-care hospital inpatient coding experience.
• For registered nurses: two years of acute nursing experience.
• RHIA or RHIT with CCS certification; alternatively, an RN with a current, valid Texas license to practice and CCS is highly desired.
• CCDS or CDIP credential must be obtained on or before the third-year hire date.
• Superior coding expertise and critical-thinking skills, including the ability to solve problems using current policies, procedures, guidelines, and regulations.
• Technical competency and fluent navigation of electronic medical record applications, coding decision-support tools including encoders, abstracting and billing systems, electronic medical records used as coding source documents, and associated computer applications.
• Experience with Microsoft Office applications, including Excel, Word, Outlook, and PowerPoint.
• Ability to work independently and productively with minimal guidance and without direct supervision.
• Strong analytical and critical-thinking skills, attention to detail, organization, writing, interpersonal, and communication skills; ability to maintain confidentiality and build positive relationships.
• Strong verbal and written communication skills and fluent English.
• Ability to give presentations and adapt communication style when interacting with providers.
• Ability to provide excellent customer service in interactions with all individuals.
• Demonstrated coding knowledge and proficiency, including the ability to articulate coding guidelines and procedures.
• Ability to work independently in a multitasking environment, take initiative, use sound judgment, meet tight deadlines, remain flexible, and embrace change.

Nice To Haves

• Master’s degree in a health-related field.
• One to two years of APR/DRG coding and clinical validation auditing experience in a pediatric setting.
• ICD-10-CM training.
• Pediatric ER or ICU nursing experience for RNs.
• CCDS credential and/or CDIP credential, along with knowledge of ICD-10 and APR-DRGs.
• CDI experience.
• ICD-10-CM/PCS training.
• Proficiency in computer-assisted coding/CDI tools, automated coding workflow processes, and management of coded data integrity.

Responsibilities

• Review charts for documentation accuracy and specificity, coding accuracy, and APR-DRG assignment compliance.
• Analyze patient care documentation after coding and before billing; assign codes as needed.
• Verify Present on Admission status and DRGs and validate that documentation supports code specificity and compliance requirements.
• Perform pre-bill audit reviews and track, trend, and report audit results.
• Provide feedback and education to providers and coders on documentation improvement opportunities.
• Review payer coding denials for appropriate and accurate coding.
• Review concurrent admissions and create documentation clarification queries for providers.
• Serve as a liaison between coding staff, Physician Advisors, and providers.
• Communicate with and educate Physician Advisors and providers regarding documentation improvement.
• Report audit results to appropriate individuals, groups, and committees monthly or as requested.
• Foster relationships among disciplines.
• Maintain current knowledge of clinical documentation improvement, Epic systems, coding schemes, APR-DRG groupers, organizational policies and procedures, and regulatory requirements and guidelines for documentation, coding, and billing/reimbursement.
• Assist in setting goals and priorities for the coding team.

What This Job Offers

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