Clinical Chart Auditor

California Retina Consultants; Palmdale (CA); On-site; USD 60,000 - 75,000; Full time

Benefits offered by this job

Medical Insurance Plans

Vision Insurance Plan

Dental Insurance Plan

401K Contribution

Life Insurance

Sick, Vacation, and Holiday Pay

Job summary

A prominent retina-only ophthalmology group in California seeks a Clinical Chart Auditor to ensure clinical documentation integrity and coding accuracy. The successful candidate will conduct systematic reviews of patient medical records, perform internal audits, and collaborate with clinical teams. Preferred qualifications include a Bachelor's degree and experience as a scribe. The role offers competitive benefits and the potential for remote work options based on qualifications.

Qualifications

• 2+ years of experience as a scribe in an ophthalmology setting preferred.
• 1+ years as a lead scribe and/or clinical trainer preferred.

Responsibilities

• Conduct systematic reviews of patient medical records for documentation integrity.
• Perform routine internal chart audits on patient encounters.
• Document and track compliance gaps and deficiencies.
• Analyze audit findings and present insights for improvements.

Skills

Knowledge of retina-specific documentation requirements

Proficiency with Nextech EHR and EPM systems

Strong analytical skills

Excellent communication skills

Organizational abilities

Problem-solving abilities

Ability to work independently

Conflict resolution

Education

Bachelor's degree

Ophthalmic Scribe Certified (OSC)

Ophthalmic Coding Specialist Retina (OCSR)

CRT, COA, COT, COMT

Job description

The Clinical Chart Auditor is responsible for conducting systematic reviews of patient medical records to ensure clinical documentation integrity and coding accuracy. This role is essential for minimizing audit risks, optimizing revenue cycle performance, and supporting regulatory adherence for retina-specific services. Remote work options may be available based on operational needs, candidate qualifications, and practice location requirements.

Duties / Responsibilities

• Perform routine internal chart audits (retrospective, concurrent and prospective) on a representative sample of patient encounters.
• Verify alignment between clinical documentation, ICD-10 diagnoses, CPT/HCPCS procedure codes, and supporting elements (physician orders, informed consents, medical necessity, etc.).
• Identify, document, and track documentation deficiencies and compliance gaps (cloned notes, insufficient chief complaints, lack of medical necessity, unsupported level of the office visit CPT, etc.), generating detailed audit reports.
• Analyze audit findings to produce trended data on clinical documentation integrity accuracy rates and risk areas, presenting actionable insights to leadership, billing, and clinical teams for process improvements.
• Collaborate with clinical trainers, billing specialists, scribes and physicians to provide targeted feedback, resolve discrepancies, and deliver education on documentation standards, coding guidelines, and audit best practices.
• Monitor key performance indicators (KPIs) for clinical documentation integrity and coding accuracy, contributing to the practice's overall compliance program.
• Facilitate MIPS success by gathering and auditing required clinical data and collaborating with the clinical team to implement best practices.
• Manage prescription drug processes including handling Rx refills, processing prescription drug change requests, and facilitating prior authorizations (PAs) to support timely and accurate medication delivery in coordination with clinical teams.

Other Duties

• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.
• Duties, responsibilities, and activities may change at any time with or without notice.

About the Candidate

Education and Experience

• Bachelor's degree preferred.
• Ophthalmic Scribe Certified (OSC) highly preferred.
• Ophthalmic Coding Specialist Retina (OCSR) highly preferred.
• CRT, COA, COT, COMT highly preferred.
• 2+ years of experience as a scribe in ophthalmology setting (retina subspecialty exposure preferred)
• 1+ years as a lead scribe and/or clinical trainer highly preferred.

Preferred Skills / Abilities

• Demonstrated knowledge of retina-specific documentation requirements.
• Proficiency with Nextech EHR and EPM systems.
• Knowledge of coding, HIPAA and other charting regulatory requirements.
• Strong analytical, communication, and interpersonal skills.
• Ability to follow instructions, work well with others and alone with minimal supervision.
• Excellent organizational and problem-solving abilities.
• Ability to work effectively in a fast-paced and dynamic environment.
• Ability to handle conflict resolution and hold staff accountable.

All applicants considered for this role must be able to travel to other nearby locations.

Who We Are

California Retina Consultants (CRC) is one of the largest, most highly respected retina-only ophthalmology groups in the United States and is committed to providing state-of-the-art treatments. All California Retina Consultant physicians are board certified/eligible by the American Board of Ophthalmology and specialize exclusively in diseases and surgery of the retina, vitreous, and macula. Our physicians have studied at the most prestigious medical center and universities and have each achieved numerous honors and awards. In addition, CRC participates in national cutting edge clinical and investigator-sponsored trials, participating in hundreds since it's founding.

CRC offers the following competitive benefits for full-time eligible employees after the introductory period:

• Medical Insurance Plans
• Vision Insurance Plan
• Dental Insurance Plan
• 401K Contribution
• Life Insurance
• Sick, Vacation, and Holiday Pay

Equal Opportunity Employer

California Retina Consultants is proud to be an Equal Employment Opportunity and an Affimative Action Employer. We are committed to creating an inclusive work environment that celebrates diversity.

(All offers are contingent upon satisfactory background check and pre-employment drug screen.)