Clinical Documentation Auditor

🔥 2 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 10%

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Wellstar Health System

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1992

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Wellstar Health System is a comprehensive healthcare organization dedicated to providing personalized and compassionate care to patients in Georgia and South Carolina. With a diverse range of career opportunities, Wellstar supports its employees' career growth and wellbeing through a positive culture, excellent benefits, and a focus on diversity, equity, and inclusion. The organization emphasizes the importance of treating both patients and staff with respect and care, making it a sought-after workplace in the healthcare industry. Wellstar is committed to offering high-quality healthcare services and maintaining strong community engagement.

📋 Description

• Perform CDI and coding audits to improve financial and AHRQ quality metrics • Collaborate with the CDI Education Lead on stakeholder education and provider education materials • Perform staff, PSI, HAC, HAI, mortality, validation, and special project reviews • Audit medical records for clinical documentation improvement opportunities • Conduct real-time audits of reviews, queries, and reports • Review data and trends to identify improvement opportunities • Provide feedback and education to CDI teams and coders on documentation and coding best practices • Review clinical documentation remotely during patient admissions • Communicate documentation opportunities to physicians • Perform hospital-wide medical record reviews to improve documentation quality, completeness, accuracy, coding compliance, reporting, and patient outcomes • Submit compliant electronic queries to clinicians and provide follow-up • Escalate unanswered queries according to the Wellstar Query Escalation process • Reconcile records daily in the Solventum/3M 360 Encompass CDI tool • Maintain daily, weekly, and monthly metrics and meet productivity standards • Participate in departmental meetings, conference calls, and presentations • Support hospital compliance with federal and state regulatory requirements • Review quarterly Coding Clinic changes and update processes accordingly • Maintain knowledge of coding and billing rules to support appropriate reimbursement • Perform other duties as assigned

🎯 Requirements

• Associate's degree in Nursing, bachelor's degree in Health Science, accredited Health Science program, or doctorate in Medicine • Clinical Documentation Specialist certification within 180 days or Clinical Documentation Improvement Practitioner certification within 180 days • Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist • Minimum 5 years of healthcare experience • Prior CDI/Coding auditor experience preferred • Prior inpatient case management or utilization review experience preferred • RNs must hold an active nursing license upon hire • Non-clinical/coding candidates must have at least one active/current certification upon hire: CCS, CPC, RHIA, or RHIT • Strong understanding of disease processes, clinical indications and treatments, and provider documentation requirements • Familiarity with an encoder and current knowledge of Coding Clinic Guidelines and federal DRG updates for MS and APR • CDI/Coding chart review experience • Expert knowledge of Clinical Documentation Integrity, including productivity, quality, education, training, compliance auditing, data analysis, trending, report management, and performance improvement • Strong communication, critical thinking, time management, training, and peer development skills • Proficiency with Microsoft Word, Excel, and PowerPoint • Proficiency with CDI technology tools and data analysis • Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives • Ability to collaborate with medical staff, clinical departments, and facility leadership • Ability to prepare and maintain records and written reports • Epic and Solventum/3M 360 Encompass experience preferred

🏖️ Benefits

• Full-time employment • Remote work for clinical documentation reviews, audits, and related duties • Supportive work environment where contributions and ideas are valued • Opportunity to serve with compassion, pursue excellence, and honor every voice • Meaningful work improving patient outcomes and healthcare quality • Professional education and development through stakeholder, CDI team, and coder education