Clinician Documentation Auditor & Educator

US Acute Care Solutions • Virtual OH, OH

1d • Remote

About The Position

The Clinician Documentation Auditor & Educator (CDAE) performs chart reviews, issues communications, and interacts with clinicians in an effort to assure complete and accurate documentation of the patient’s clinical picture and the treatment provided. Responsible for analyzing reports for documentation and coding trends.

Requirements

• Beginning and/or intermediate clinical assessment skills typically gained and maintained through accredited CDI organizations and certification programs.
• Analytic skills and ability to process assigned duties in an organized manner.
• Knowledge of and experience using ICD-10-CM and CPT and HCPCS coding.
• Knowledge of professional coding in specialty of emergency medicine and other specialty service lines
• Knowledge and understanding of multiple electronic medical records
• Knowledge of and skill using personal computers in a Windows environment with an emphasis on Microsoft Office including Word, PowerPoint and Excel.
• Ability to identify, research and solve problems and discrepancies.
• Ability to professionally and effectively communicate speaking in public arenas or in writing with clinicians, coworkers and management.
• Ability to maintain confidentiality.
• Ability to effectively perform in a multi-task work environment.
• Completes work with limited degree of supervision
• Strong organizational skills
• Adaptability – maintaining effectiveness when experiencing major changes in work tasks or the work environment; able to adapt to change in environment and/or circumstances with a positive outlook; and adjusting effectively to work within new work structures, processes, requirements, or cultures
• Initiative – independently takes prompt proactive steps towards problem resolution
• Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations. Cultivates strategic customer relationships and ensures that the customer perspective is the driving force behind all value-added business activities
• PC skills - demonstrate proficiency in software applications
• High school diploma or equivalent.
• RN, RHIT, RHIA, CPC, or CCS-P with CPMA or other job-related accreditation required.
• At least three years of coding experience or equivalent training/education.
• Demonstrated knowledge of industry guidelines and regulations required.

Responsibilities

• Obtains and promotes appropriate clinical documentation through extensive interaction with clinicians and coding staff to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate.
• Reviews medical records and identifies potential gaps in clinical documentation.
• Queries clinicians via approved coder communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk of mortality.
• Maintains or exceeds established quality and productivity standards.
• Works closely with coding staff to assure LOS coded was supported by documentation.
• Demonstrates basic knowledge of coding standards and application to ongoing evaluation of medical record documentation.
• Collaborates with other Sr. Clinician Documentation Educator (Sr.,CDE) to develop and implement clinician/coder education based on chart review findings.
• Identifies strategies through data gathering and analysis of trends to establish recommendations for complete, accurate clinical documentation.
• Other duties as assigned

Benefits

• Medical, dental, and vision insurance options
• Health savings accounts (HSA) and flexible spending accounts (FSA)
• 401(k) employee and employer contributions
• Paid time off, including vacation, sick leave, and company holidays
• Paid parental leave & family support benefits
• Short-term and long-term disability insurance
• Life and accidental death & dismemberment (AD&D) insurance
• Employee assistance programs & wellness resources
• Bonus eligibility
• Equity
• Other incentive programs

What This Job Offers

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