Clinical Documentation Auditor

Cigma Medical Coding Academy; Ernakulam; On-site; INR 350,000 - 650,000; Full time

Job summary

Cigma Medical Coding Academy in Kerala, India seeks a detail‑oriented CDI Auditor to review clinical documentation for accuracy and compliance with ICD-10-CM/PCS, CPT, and DRG guidelines, and to ensure medical necessity is clearly demonstrated.

You will collaborate with CDI specialists, coders, and physicians, identify documentation gaps, and prepare audit reports while staying current with regulatory changes and industry best practices.

Responsibilities

• Conduct regular, detailed audits of clinical documentation in medical records to ensure accuracy, completeness, and compliance with ICD-10-CM/PCS, CPT, and DRG guidelines.
• Evaluate provider documentation to ensure that the medical necessity is established and coding reflects the severity of illness, risk of mortality, and overall resource utilization.
• Identify documentation deficiencies and trends.
• Provide constructive feedback and recommendations for improvement.
• Collaborate with CDI specialists, coders, and physicians to clarify documentation and resolve inconsistencies.
• Prepare detailed audit reports, including findings, trends, and opportunities for improvement.
• Assist in developing and delivering education and training materials for providers and clinical staff regarding documentation standards and best practices.
• Stay current with coding guidelines, regulatory changes (CMS, Joint Commission, etc.), and industry best practices.
• Participate in quality improvement initiatives and support internal and external audits as needed.

Job description

Job Description

• Conduct regular, detailed audits of clinical documentation in medical records to ensure accuracy, completeness, and compliance with ICD-10-CM/PCS, CPT, and DRG guidelines.
• Evaluate provider documentation to ensure that the medical necessity is established and coding reflects the severity of illness, risk of mortality, and overall resource utilization.
• Identify documentation deficiencies and trends.
• provide constructive feedback and recommendations for improvement.
• Collaborate with CDI specialists, coders, and physicians to clarify documentation and resolve inconsistencies.
• Prepare detailed audit reports, including findings, trends, and opportunities for improvement.
• Assist in developing and delivering education and training materials for providers and clinical staff regarding documentation standards and best practices.
• Stay current with coding guidelines, regulatory changes (CMS, Joint Commission, etc.), and industry best practices.
• Participate in quality improvement initiatives and support internal and external audits as needed.