Clinical Documentation Auditor and Educator

Moffitt Cancer Center; Tampa (FL); On-site; USD 75,000 - 95,000; Full time

Job summary

A leading cancer research organization in Tampa, Florida is seeking a Clinical Documentation Auditor and Educator to enhance the quality and accuracy of medical documentation. This role requires a Bachelor's degree and extensive clinical experience, including previous auditing experience. The ideal candidate will conduct audits, provide training, and collaborate with clinical teams to improve documentation practices. This position is on site and offers a dynamic workplace dedicated to patient care.

Qualifications

• Minimum eight years acute clinical care experience.
• Minimum one year as a clinical documentation integrity auditor experience.
• Knowledge of healthcare regulatory environment.

Responsibilities

• Drive improvements in medical documentation accuracy.
• Perform quality review and audits.
• Provide education and training to clinical providers.

Skills

Analytical skills

Communication skills

Organizational skills

Education

Bachelor's Degree in Nursing, HIM, or another healthcare-related field

Tools

MS Office

Optum 360 eCAC

Cerner EHR

Job description

Clinical Documentation Auditor and Educator

At Moffitt Cancer Center, we strive to be the leader in understanding the complexity of cancer and applying these insights to contribute to prevention and cure. Our team of over 9,000 is dedicated to serving our patients and creating a workspace where every individual is recognized and appreciated. Moffitt is a National Cancer Institute-designated Comprehensive Cancer Center in Florida, and is recognized for Magnet designation in nursing excellence. We are ranked among top cancer centers nationally by Newsweek and U.S. News & World Report.

Overview: The Clinical Documentation Auditor and Educator will drive improvements across the organization in the quality, completeness, and accuracy of medical record documentation through comprehensive audits, educational initiatives, and data analysis. This role will identify patterns, trends, and opportunities for the CDI team and the Clinical Documentation Second Level Reviewer across all acute care facilities to enhance documentation accuracy and outcomes. The role will also perform large-scale retrospective audits at the request of hospital clients and provide education to clinical providers. This position reports to the CDI Manager and works independently meeting deadlines with minimal supervision.

Responsibilities

• Quality review and audits
• Education and training
• Data analysis
• Perform other duties as assigned

Credentials and Experience

• Bachelor's Degree in Nursing, HIM, or another healthcare-related field
• Minimum eight (8) years acute clinical care experience
• Minimum one (1) year as a clinical documentation integrity auditor experience
• Minimum eight (8) years Clinical Documentation Integrity experience
• Minimum one (1) year as a clinical documentation integrity auditor experience
• Any one of the following certifications is required, or an active RN may satisfy the certification requirement in lieu of a listed certification

Certifications

• CCDS — Certified Clinical Documentation Specialist, from ACDIS
• CDIP — Certified Documentation Integrity Practitioner, from AHIMA
• CDEI — Certified Documentation Expert Inpatient, from AAPC
• ICD-10-CM and ICD-10-PCS coding and query process knowledge
• Ability to recognize opportunities for documentation improvement and discuss with providers to address opportunities
• Proficient in MS Office, Optum 360 eCAC, Cerner EHR
• Strong organizational, analytical, interpersonal and writing skills
• Dependable, self-directed with critical thinking, problem solving and deductive reasoning
• Knowledge of healthcare regulatory environment
• Understanding and support of clinical documentation management strategies
• Flexibility to accommodate clinician schedules
• Knowledge of Medicare, Medicaid and commercial payer regulations, charging and coding guidelines
• Knowledge of Case Mix Index and how it is influenced

Preferred Experience

• 4 years' experience in oncology

Preferred Skills/Specialized Training

• Extensive ICD-10-CM, ICD-10-PCS coding knowledge and extensive knowledge of query process