Clinical Documentation Auditor and Educator

Position Highlights:

The CLINICAL DOCUMENTATION AUDITOR AND EDUCATOR will drive improvements across the organization in the quality, completeness, and accuracy of medical record documentation through comprehensive audits, educational initiatives, and data analysis. This role will focus on identifying patterns, trends, and opportunities for the CDI team and the Clinical Documentation Second Level Reviewer across all acute care facilities, aiming to enhance documentation accuracy and outcomes.

The CLINICAL DOCUMENTATION AUDITOR AND EDUCATOR will also perform large-scale retrospective audits at the request of hospital clients and provide education to clinical providers.

This position reports to the CDI Manager and works independently meeting deadlines with minimal supervision.

Responsibilities:

• Quality review and Audits.
• Education and training.
• Data Analysis.
• Reconciliation.
• Perform other duties as assigned.

Credentials and Experience:

• Bachelor's Degree in Nursing, HIM, or another Healthcare related field.
• A minimum eight (8) years acute clinical care experience AND A minimum one (1) year as a clinical documentation integrity auditor experience.
  OR
• A minimum eight (8) years Clinical Documentation Integrity experience AND A minimum one (1) year as a clinical documentation integrity auditor experience.
• Any (one) of the following certifications is required.
  • *in lieu of a certification listed above, an (active) RN will satisfy the certification requirement.

Certification:

Any "one" of the following certifications is required upon hire:

• (CCDS) Certified Clinical Documentation Specialists from ACDIS.
• (CDIP) Certified Documentation Integrity Practitioner from AHIMA.
• (CDEI) Certified Documentation Expert Inpatient from AAPC.

Minimum Skills/Specialized Training Required:

• ICD-10-CM and ICD-10-PCS coding and query process knowledge.
• Ability to recognize opportunities for documentation improvement, and hold collaborative discussions with providers to address the opportunities in documentation.
• Proficient in computer skills including: MS Office, Optum 360 eCAC, Cerner EHR.
• Organized, analytical, superior interpersonal and writing skills.
• Dependable, self-directed with critical thinking, problem solving, and deductive reasoning.
• Knowledge of healthcare regulatory environment.
• Understand and support clinical documentation management strategies.
• Must be flexible to accommodate clinician schedules.
• Knowledge of Medicare, Medicaid and Commercial payers regulations, charging and coding guidelines.
• Knowledge of Case Mix Index and how it is influenced.

Preferred Experience:

• 4 years' experience in oncology.

Preferred Skills/Specialized Training:

• Extensive ICD-10-CM, ICD-10-PCS coding knowledge and extensive knowledge of query process.