Clinical Documentation Specialist – Audit and Education

🕒 September 28

🇺🇸 United States – Remote

💵 $86.6k - $160.9k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🏥📝 Medical Writer

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Ascension

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare • Healthcare Insurance • Non-profit

Ascension is a faith-based healthcare organization dedicated to transformation through innovation across the continuum of care. As one of the leading non-profit and Catholic health systems in the U. S. , Ascension is committed to delivering compassionate, personalized care to all, particularly focusing on those living in poverty and the most vulnerable populations. Operating over 2,600 sites of care, including 151 hospitals, Ascension offers a variety of services, including physician practice management and clinical care management, while emphasizing a mission of community benefit.

📋 Description

• Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS • Support the professional development of the CDI team • Provide provider-facing education to improve clinical documentation practices • Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries • Maintain internal audit tools • Track performance metrics and present findings to leadership regularly • Evaluate query appropriateness, clinical evidence, and alignment with ICD-10-CM/PCS, UHDDS, and CMS coding rules • Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best 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 • 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) • Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance • Must have a Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)

🏖️ 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) • Tuition 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

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