Clinical Chart Auditor

California Retina Consultants; Santa Barbara (CA); Remote; USD 75,000 - 110,000; Full time

Job summary

Sacramento Native American Health Center, Inc is seeking a Clinical Chart Auditor to conduct systematic reviews of patient records ensuring documentation integrity and accurate coding for retina services. The role supports revenue cycle optimization and regulatory adherence.

Remote work options may be available, with residency considerations for Central California. Candidate should have OSC and OC SR certifications, experience in ophthalmology scribing, and proficiency in Nextech EHR and MS

Qualifications

• Bachelor's degree preferred.
• OSC certification required.
• OCSR certification required.
• 2+ years as ophthalmology scribe; retina exposure preferred.
• 1+ years as lead scribe or clinical trainer preferred.

Responsibilities

• Perform routine internal chart audits (retrospective, concurrent and prospective) on a representative sample of patient encounters.
• Verify alignment between clinical documentation, ICD-10, CPT/HCPCS codes and supporting elements.
• Identify documentation deficiencies and compliance gaps and generate audit reports.
• Analyze audit findings and present actionable insights to leadership and teams.
• Collaborate with trainers, billing specialists and physicians to provide feedback and education on documentation standards and coding guidelines.
• Monitor KPIs for clinical documentation integrity and coding accuracy.
• Support MIPS by auditing required clinical data with the clinical team.
• Manage prescription drug processes including refills and prior authorizations.

Skills

Analytical skills

Communication skills

Interpersonal skills

Organizational skills

Education

Ophthalmic Scribe Certified (OSC)

Ophthalmic Coding Specialist Retina (OCSR)

CRT/COA/COT/COMT preferred

2+ years ophthalmology scribe experience

Lead scribe/trainer experience

Tools

Nextech EHR

EPM systems

MS Office

Job description

Contact information

• Job Category Clinical Operations, Chart Auditor, Medical Assistant
• Industry Healthcare, Ophthalmology, Clinical Operations
• Employee Type Nonexempt FT
• Manage Others No

• Name Whitney Andresen

Description

Clinical Chart Auditor

Job Summary

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.

This is a Remote position; however, all candidates considered for this position must currently reside within Central California.

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.

Requirements

About the Candidate

Education and Experience

• Bachelor's degree preferred.
• Ophthalmic Scribe Certified (OSC) required .
• Ophthalmic Coding Specialist Retina (OCSR) required .
• 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.
• Proficiency with Nextech EHR and EPM systems.
• Knowledge of coding, HIPAA and other charting regulatory requirements.
• Proficiency with MS Office Tools (Word, Excel, PowerPoint, SharePoint, OneNote, OneDrive).
• 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.

Summary

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
• D ent a l 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 Aff… . 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.)