CDI Auditor: Elevate Clinical Documentation Quality

e4health; Pittsburgh (Allegheny County); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

401(k) with company match

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability insurance

Paid time off (PTO)

Job summary

e4health seeks a CDI Auditor to perform quality assurance reviews of patient records, ensuring accurate documentation reflecting illness severity and complexity. The role involves evaluating queries from a compliance perspective and applying AHIMA/ACDIS standards across records reviewed by Customer CDS teams.

You will review accounts for opportunities to improve documentation quality, partnering with Customer CDS staff, and utilizing e4health audit tools. Travel up to 15% may be required.

Qualifications

• Certification in ACDIS CCDS or AHIMA CDIP is required.
• 3+ years of clinical documentation experience in an acute care facility is required.
• 2+ years of CDI auditing experience.
• RN license or graduation from medical school with 5+ years acute care experience preferred.
• Thorough understanding of MS and APR DRG methodologies and compliant query practices.

Responsibilities

• Review medical records for complete and accurate documentation of diagnoses and procedures.
• Identify missed documentation opportunities within medical records.
• Evaluate queries from a compliance perspective using ACDIS/AHIMA guidelines as standard.
• Assess adherence to CDI processes/procedures.
• Adhere to guidelines by ACDIS, AHIMA, and related bodies.
• Understand healthcare business aspects such as MS and APR DRG payer issues and risk models.
• Collaborate with Customer, team members, and management to meet assignment needs.
• Utilize Customer and e4health audit software for reviews and reporting.
• Maintain confidentiality of all patient information per HIPAA.

Skills

Analytical skills

Communication skills

HIPAA compliance

ICD-10-CM/ICD-10-PCS knowledge

DRG methodologies knowledge

MS Office proficiency

Education

ACDIS CCDS or AHIMA CDIP certification

RN license or MD/DO with acute care experience

BSN (preferred)

Tools

Microsoft Excel

Microsoft Word

Microsoft Outlook

Job description

e4health seeks a CDI Auditor to perform quality assurance reviews of patient records, ensuring accurate documentation reflecting illness severity and complexity. The role involves evaluating queries from a compliance perspective and applying AHIMA/ACDIS standards across records reviewed by Customer CDS teams.

You will review accounts for opportunities to improve documentation quality, partnering with Customer CDS staff, and utilizing e4health audit tools. Travel up to 15% may be required.