Clinical Documentation Auditor

Wellstar Health System; New York (NY); On-site; USD 90,000 - 120,000; Full time

Job summary

The Wellstar Health System CDI Auditor evaluates clinical documentation quality and coding accuracy across patient records, partnering with providers and coders to ensure proper severity and service level.

You will drive CDI activities, perform audits, provide feedback, and support education to improve documentation and coding compliance within the organization.

Qualifications

• Associates Nursing or Bachelors Health Science required.
• Certificates in clinical documentation or coding preferred.
• Experience in acute care CDI/coding auditing beneficial.

Responsibilities

• Audit medical records to improve documentation and coding accuracy.
• Provide feedback and education to clinicians and CDI staff.
• Maintain CDI metrics and ensure regulatory compliance.

Skills

CDI auditing

Coding knowledge

Clinical documentation

Healthcare compliance

Communication skills

Problem-solving

Data analysis

Education

Associates Nursing

Bachelors Health Science

Accredited Health Science Program

Doctorate Medicine

Tools

Epic

Encompass

Solventum

3M Encompass

Job description

How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Work ShiftJob Summary

The Clinical Documentation Integrity (CDI) Auditor must be good at problem-solving, clinical and coding knowledge, and communicating and collaborating. The CDI Auditor evaluates the quality and accuracy of the clinical documentation in the patient record, and works with the CDI team, providers, and coders to make sure the record shows the patient's clinical severity and level of service. The CDI auditor also looks at the performance of the CDI team and finds areas to improve. CDI auditor audits provider documentation, CDI and coding accuracy to confirm or find ways to improve proper documentation. CDI auditor gives feedback and education to the CDI team and coders on documentation and coding best practices and helps the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.

Core Responsibilities and Essential Functions

1. Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, and collaboration with CDI Education Lead to ensure stakeholder education. Assists CDI Education Lead remotely with preparing provider education materials, gathering articles or other information for presentations and meetings. Performs staff, PSI, HAC, HAI, mortality, etc. reviews remotely as assigned by the management. a) Initiates audits and prepares findings to assist CDI Education Lead in preparing and providing regular CDI education to stakeholders based on findings, trends, industry events and based on management needs b) Audits medical records to determine opportunities as they relate to clinical documentation improvement, PSI, HACs, mortality, etc. c) Conducts and provides real-time audits of reviews, queries and reports and provide feedback on process, query opportunities and query compliance. Reviews data and trends to identify additional areas of opportunity. d) Conducts Validation and Special Project tasks to support the CDI Leadership and ensure appropriate data is entered, captured, and reported in the CDI Software for the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. e) Functions as a Super User with CDI Software and all other applications utilized in this position.

2. Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. a) Performs hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes. b) Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population. c) Ensure queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures. d) Provides appropriate follow-up on all queries. e) Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist. f) Provides appropriate follow up to CDI Education Lead for education on queries as needed. g) Notifies CDI Education Lead immediately when query education is needed and provides all data necessary to the CDI Education Lead to assist in the delivery of education. h) Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated. i) Maintains required daily/weekly/monthly metrics and meets productivity standards. j) Participates in required departmental meetings, conference calls and presentations. k) Adheres to departmental Policies and Procedures. l) Participates in assuring hospital compliance with Federal and State regulatory requirements.

3. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. a) Participates in assuring hospital compliance with Federal and State regulatory requirements. b) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education

Associates Nursing or Bachelors Health Science or Accredited Program Health Science or Doctorate Medicine

Required Minimum License(s) and Certification(s)

All certifications are required upon hire unless otherwise stated.

Cert Clin Document Specialist within 180 Days or Cert Document Improvement Prac within 180 DaysReg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof Coder-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred

Additional License(s) and Certification(s)

It is expected that all RNs are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required or It is expected that all non-clinical (coding) background candidates have at least one of the following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or (4) Registered Health Information Technician (RHIT) from AHIMA Upon Hire Required

Required Minimum Experience

Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and Minimum 5 years healthcare experience Required and Prior experience of working as a CDI/Coding auditor is preferred Preferred and Prior experience of working in inpatient case management or utilization review is preferred Preferred and

Required Minimum Skills

Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR) Epic and Solventum/3M 360 Encompass experience is preferred Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives CDI/Coding chart review experience required Excellent communication skills, employing tact and effectiveness Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives Excellent critical thinking skills, with the ability to recommend and implement practical and efficient solutions Must have proficient computer skills in Microsoft Apps, such as Word, Excel, and PowerPoint, as well as CDI technology tools required for the job functions Must be comfortable with doing data analysis, and preparing and maintaining records and written reports Drives optimal use of the CDI technology tool and reporting capabilities Excellent time management, training, and peer development skills

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