Clinical Documentation Auditor/Educator (Remote)

Memorial Hermann; Houston (TX); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Clinical Documentation Improvement (CDI) Auditor Educator to enhance the quality and accuracy of medical record documentation. This role involves conducting audits, analyzing trends, and providing education to clinical staff across multiple facilities. With a focus on improving documentation practices, the CDI Auditor will play a pivotal role in advancing patient care and ensuring compliance with clinical guidelines. If you are passionate about making a difference in healthcare and possess strong analytical and communication skills, this opportunity is perfect for you.

Qualifications

• 3-5 years of CDS experience in clinical documentation improvement.
• Experience in auditing and education for Clinical Documentation Specialists.

Responsibilities

• Conduct audits of clinical documentation to ensure quality and compliance.
• Develop and deliver training to improve documentation quality.

Skills

Clinical Documentation Improvement

CDIS Auditing

Communication Skills

Analytical Skills

MS Office Proficiency

Problem-Solving Skills

Organizational Skills

Education

Bachelor's of Nursing

Master’s Degree in Nursing or Management

Tools

3M Coding and Reimbursement Software

Cerner EMR

Job description

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The Clinical Documentation Improvement (CDI) Auditor Educator will facilitate improvement system-wide in the overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation, education and data analysis. The incumbent will be responsible for identification of patterns, trends, and opportunities for the entire CDI team, at all acute care facilities, to improve accuracy and outcomes. This position will also be responsible for assisting with large retrospective audits, at the request of hospital clients system-wide, and for educating physicians, if needed. Reports to the CDI Quality/Education Manager. The CDI Auditor reports to the Director as an individual contributor and provides recommendations on clinical documentation quality improvement and education programs.

Job Description

• Must Have Clinical Documentation Experience To Be Considered
• Memorial Hermann now hiring for an experienced, remote CDI Specialist in the following states:
• Texas
• Louisiana
• Oklahoma
• Florida
• Georgia
• Tennessee
• South Carolina
• Must reside in one of the above states to be considered
• Minimum Qualifications

Education: Bachelor's of Nursing, required; Master’s Degree in Nursing or Management preferred

Licenses/Certifications:

• Current State of Texas license or temporary/compact license to practice professional nursing
• Certified Clinical Documentation Specialist (CCDS) required; AHIMA ICD-10-CM/PCS Trainer preferred

Experience / Knowledge / Skills:

• Minimum of three (3) to five (5) years of CDS experience
• Previous CDIS auditing and education experience and/or CDIS supervisory/management background preferred
• Strong computer proficiency including MS Office (Word, Excel, Outlook) and 3M Coding and Reimbursement software; experience with Cerner EMR preferred
• Excellent communication, analytical and problem-solving skills
• Strong organizational skills and attention to detail
• Highly analytical with risk assessment, impact analysis, and problem-solving skills
• Self-motivated, team-oriented, able to take direction
• Flexible, able to multi-task and prioritize daily workload, including concurrent chart reviews

Principal Accountabilities

• Audit case reviews and queries of Clinical Documentation Specialists (CDIS) to ensure quality and compliance, using audit tools developed.
• Track, analyze, and report audit findings for CDIS, hospital regions, and system-wide to management.
• Identify knowledge gaps; provide explanations on missing, unclear, conflicting, or non-compliant documentation.
• Stay current on clinical and coding guidelines, including quarterly Coding Clinics, especially as they relate to physician documentation in an ICD-10 environment.
• Assist in maintaining quality, timely, and complete health records; serve as a resource for clinical documentation improvement.
• Develop and deliver training and education to physicians and CDIS staff to improve documentation quality and accuracy.
• Use audit tools to conduct clinical quality audits.
• Develop and update policies and procedures related to CDIS audit functions; refine audit tools collaboratively.
• Collaborate on post-discharge documentation and coding audits as requested by hospital clients.
• Ensure safe patient care; adhere to policies, procedures, standards, and budget constraints.
• Promote professional growth; serve as preceptor, mentor, and resource.
• Model Memorial Hermann’s service standards by providing safe, caring, personalized, and efficient experiences.
• Perform other duties as assigned.