Clinical Documentation Audit Specialist

Jefferson Health; Abington Township (PA); On-site; USD 70,000 - 100,000; Full time

Benefits offered by this job

Medical insurance

Retirement plans

Tuition assistance

Job summary

Jefferson Health in Abington, PA is seeking a Clinical Documentation Audit Specialist to perform expert CDI reviews of medical records, ensure CMS and regulatory compliance, and prepare targeted queries for physicians. You will support enterprise-wide quality initiatives and participate in committees to enhance documentation quality.

This role requires strong coding knowledge, Epic EHR experience, and collaboration with CDI teams.

Qualifications

• Minimum one year experience as a CDI specialist.
• Strong knowledge of ICD-10 diagnosis and procedure coding conventions.
• Experience with quality record reviews and patient safety indicators is preferred.
• Excellent written and verbal communication; ability to collaborate across teams.
• Proficiency in Microsoft Office tools (Outlook, Word, Excel, PowerPoint).

Responsibilities

• Perform expert level CDI reviews of designated medical records for CMS and regulatory compliance.
• Prepare clear, compliant queries to physicians for documentation clarification.
• Support enterprise performance improvement and coding accuracy across the organization.
• Assist with quarterly quality record review audits of CDI staff and workflows.
• Participate in hospital committees to improve documentation quality and processes.

Skills

Clinical record reviews

ICD-10 coding

Epic EHR

3M encoder coding

Interpersonal communication

Data analytics

Microsoft Office

Education

Certified CCDS or CDIP

BSN/PA/medical degree preferred

Tools

Epic EHR

3M encoder

DRG system

Job description

## Clinical Documentation Audit SpecialistApplylocations: Montgomery County, PAtime type: Full timeposted on: Posted Todayjob requisition id: REQ-0032861**Job Details**Clinical Documentation Audit Specialist**Job Description**Under the direction of the Senior Director of Clinical Documentation Improvement (CDI) and CDI Manager, the CDI Audit Specialist provides expert level CDI reviews of targeted medical records throughout the enterprise to assist management in ensuring accurate quality data reporting and providing educational feedback to CDI managers. This position will support organizational goals by identifying opportunities to partner with providers to more accurately capture patients' clinical pictures to reflect Jefferson's superior patient care, participating in enterprise-wide performance improvement efforts, and demonstrating a commitment to teamwork and cooperation.1. Interacts with co-workers, visitors, & other staff consistent with the values of Jefferson.2. Accurately reviews designated medical records for completeness in documentation of diagnostic and procedural information in compliance with Center for Medicare Services (CMS), Department of Health regulatory, and financial requirements. Provides an expert level review of targeted medical records to ensure accurate data capture of patient diagnoses and procedures.3. Performs second level reviews on designated records (i.e. mortality, Patient Safety Indicator reviews, sepsis, etc.) to ensure accurate quality reporting and serves as department liaison for quality related meetings.4. Prepares well written and compliant queries to communicate with physicians and other providers regarding clarifying conflicting, missing, or incomplete documentation in the medical record.5. Supports revenue cycle initiatives in managing the load of cases that are discharged but not final billed by supporting timely CDI query follow-up in accordance with query escalation process.6. Coordinates with management to utilize expert level CDI skills to conduct quarterly quality record review audits of CDI specialists across the enterprise.7. Assists with enterprise-wide documentation improvement quality initiatives. Evaluates opportunities for CDI education and/or CDI workflow and process improvements.8. Participates on hospital committees to conduct record review studies, as necessary, to facilitate improvement in clinical documentation processes to ensure overall quality, completeness, and compliance.**Required Knowledge, Skills, and Abilities (Proficiencies):**Prior exposure to quality record reviews (i.e. Patient safety indicators, mortality) preferred. Strong working knowledge and experience in clinical record reviews, 3M encoder coding systems, Diagnostic Related Group (DRG) system, and Epic EHR system required. Expert level working knowledge of ICD-10 diagnosis and procedural coding conventions and severity of illness/risk of mortality required. Excellent interpersonal and communication skills (both written and verbal) with previous experience working collaboratively within teams required. Ability to work remotely and manage participation in multiple committees. Prior data analytic skills and understanding case mix index and DRG/all patient refined (APR) diagnosis related group systems. Strong working knowledge of Microsoft Office; Outlook, Word, Excel, PowerPoint.**Required Experience, Education, Certification:**Minimum one year experience required as a CDI specialist. Minimum of two years hands-on clinical experience either obtained through inpatient clinical nursing (i.e. RN, BSN), medical school, or residency or 5 years acute care inpatient medical coding. Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certifications required or within six months of eligibility.BSN, PA or medical graduate degree preferred. Experience with hospital acquired conditions, patient safety indicators, and risk adjustment methodology (specifically Vizient, Elixhauser, or Hierarchical Condition Category) preferred. Prior presentation and educational training skills preferred. Successful completion of Vizient Risk Adjustment Training.**Work Shift**Workday Day (United States of America)**Worker Sub Type**Regular**Employee Entity**Abington Memorial Hospital**Primary Location Address**1200 Old York Road, Abington, Pennsylvania, United States of AmericaNationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years. Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. **Benefits**Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.For more benefits information, please click here