Clinical Documentation Specialist Audit and Education

Ascension • Saint Louis, MO

4d • Remote

About The Position

Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.

Requirements

• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.
• Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)
• Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.
• Proven ability to develop engaging education content tailored to diverse audiences (clinical, coding, administrative).
• Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).

Responsibilities

• Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
• Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis.
• Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).
• Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.

Benefits

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options
• Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance
• Time to recharge: pro-rated paid time off (PTO) and holidays
• Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning
• Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources
• Family support: parental leave, adoption assistance and family benefits
• Other benefits: optional legal and pet insurance, transportation savings and more

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED