Clinical Documentation Specialist – Audit and Education

🔥 20 hours ago

🇺🇸 United States – Remote

💵 $96.2k - $134.1k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

🚫👨‍🎓 No degree required

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Ascension

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🤝 Non-profit

Healthcare • Non-profit

Ascension is one of the nation’s leading non-profit Catholic health systems focused on delivering compassionate, personalized care with special attention to vulnerable populations. In FY2025 Ascension reported providing $1. 7 billion in care for persons living in poverty and other community benefit programs plus $1. 8 billion of unreimbursed care for Medicare patients. Operating across 16 states and the District of Columbia, its network includes about 97,300 associates, 25,300 aligned providers, 90 wholly owned or consolidated hospitals and ownership interests in 29 additional hospitals; Ascension also operates 22 senior living facilities and a variety of other care sites (including home health and health clinics). Its specialties include medical services, nursing, health system operations, and healthcare technology, all grounded in its faith-based mission to bring health, healing and hope to all.

📋 Description

• Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements • Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS) • Maintain internal audit tools • Track performance metrics • Present findings to leadership on a regular basis • Develop and deliver comprehensive CDI education programs • Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices • Offer targeted documentation education to providers through presentations, individual feedback, and query response coaching

🎯 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 • Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists • Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles • Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance • 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)

🏖️ Benefits

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options • Employer-matched 403(b) • Planning and hardship resources • Disability and life insurance • Pro-rated paid time off (PTO) and holidays • Ascension-paid tuition (Vocare) • Reimbursement • Ongoing professional development and online learning • Employee Assistance Program • Counseling and peer support • Spiritual care and stress management resources • Parental leave • Adoption assistance and family benefits • Optional legal and pet insurance • Transportation savings