Clinical Documentation Integrity Auditor

POSITION SUMMARY:

The CDI Auditor is responsible for performing audits on CDIS reviews of inpatient encounters to ensure the Clinical Documentation Integrity Specialists capture all available opportunities to clarify provider documentation and therefore ensuring accurate and complete documentation specificity. The CDI auditor will monitor the CDI Specialists compliance with Stewards query policy to ensure all queries are compliant with coding requirements in alliance with AHIMA guidelines. The position requires the CDI Auditor to be highly proficient in the proper assignment of ICD-10-CM/PCS codes, to demonstrate a broad and complex clinical knowledge base, and the ability to critically analyze the CDI process, clinical documentation and opportunities for appropriate and complete documentation in the medical record.

KEY RESPONSIBILITIES:

• At the direction of the Clinical Documentation Manager of Audit/Education consistently and accurately audits clinical documentation of inpatient encounters and creates clear/concise audit reports and maintain productivity standards
• Comprehensive understanding of coding guidelines, AHA Coding Clinics, anatomy, physiology, and appropriate coding/diagnostic references along with the ability to employ these resources to audit findings.
• Knowledge of MS-DRG classification and APR-DRG classification and various reimbursement structures
• Collaborate with CDI educator and other leadership to develop and implement programs for ongoing CDI education as it relates to proper clinical coding, capture of patient care, severity and the need for accurate and complete documentation in the health record for new staff, coders, physicians, residents, nursing and allied health professionals.
• Creates clear and accurate audit findings and recommendations in written audit reports that will be used for advising and educating CDI Specialists, Auditors, Managers, and Directors throughout the organization.
• Identifies documentation issues (lacking documentation, missed physician queries, etc.) that impact coding accuracy. Clearly communicates (verbally and in written reports or summaries) opportunities for documentation improvement related to coding and CDI issues.
• Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM/PCS. Completes online education courses and attends mandatory workshops and/or seminars for CDI. Reviews AHA coding clinics quarterly and coding update publications. Attends all internal conference calls for CDI related topics and performance. Is current with ACDIS/AHIMA standards for CDI processes.
• Other responsibilities around audit, education and CDI performance as requested by CDI leadership.
• Highly proficient computer and technical skills, along with experience using MS Word, Excel, Tableau, the EMR, 3M and Iodine.
• Ability to conduct online meetings and report findings

REQUIRED KNOWLEDGE & SKILLS:

• Must be detail oriented and proven ability to work independently in a fast-paced environment
• Must demonstrate excellent interpersonal skills
• Ability to demonstrate initiative and discipline in time management and assignment completion
• Ability to work in a virtual setting under minimal supervision
• Proven ability to collaborate with coding leadership to drive overall organization goals for best in class documentation and coding

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

1. Five (5) years of Clinical Documentation Integrity experience in an acute care setting.
2. Proven ability to manage a large scope of work in a time intensive and impact driven setting.
3. A Bachelors degree in a clinical or healthcare field is required: RN, MBBS, or RHIA.
4. CCDS, CDIP and/or a coding certification required
5. Position is generally remote but may require occasional travel for meetings and onsite support to CDI team at the direction of the Manager of CDI Audit/Education.