Clinical Documentation Integrity (CDI) Auditor

CCMC Cook Children's Medical Center; Fort Worth (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

Cook Children’s Medical Center seeks a Clinical Documentation Integrity Auditor to review and improve documentation accuracy, coding precision, and APR-DRG alignment. This role verifies POA status and DRG appropriateness, conducts pre-bill audits, and tracks trends for reporting.

The auditor collaborates with providers, physician advisors, and coding staff to drive improvements and maintain regulatory compliance.

Qualifications

• Associate degree in business or clinical field required, master's desirable.
• RHIA/RHIT with CCS or RN with CCS required; CCDS/CDIP preferred and to be obtained by year 3.
• Minimum three years acute care inpatient coding experience; pediatric setting preferred.
• ICD-10-CM/PCS training desirable; strong knowledge of ICD coding and APR-DRGs.

Responsibilities

• Perform chart reviews for documentation accuracy and code specificity.
• Audit pre-bill and track audit results; report findings monthly or as requested.
• Provide education to providers and coders on documentation improvements.
• Act as liaison between Coding staff, Physician Advisors and Providers.
• Ensure POA and DRG alignment with compliance requirements.

Skills

Analytical thinking

Attention to detail

Strong communication

Critical thinking

Interpersonal skills

Fluent English

Documentation accuracy

Coding accuracy

POA/POA management

Education

Associates degree in Business or Clinical field

Master's degree in health-related field desirable

CCDS or CDIP credential preferred

RHIA or RHIT with CCS required or RN with CCS

Tools

Epic systems

ENCODERS / Coding tools

Abstracting & billing systems

Microsoft Office (Excel, Word, Outlook, PowerPoint)

Job description

Location: Medical Center - Fort Worth Department: HIM-Clinical Documentation Improvement Shift: First Shift (United States of America) Standard Weekly Hours: 40 Summary: The Clinical Documentation Integrity Auditor will perform a variety of chart reviews related to documentation accuracy and specificity, coding accuracy & APRÂDRG assignment compliance. Analyzes and evaluates patient care documentation after coding and before billing and assigns codes as needed, ensures accuracy of Present on Admission status (POA) and DRGs to validate the documentation supports code specificity per compliance requirements. Performs Pre-bill Audit (PBA) reviews, tracks, trends and reports audit results. Provides feedback & education regarding opportunities for documentation improvement to providers and coders. Provides expertise in ICD coding, DRG assignment, documentation guidance and education, and assists in setting goals and priorities for the coding team. Review payor coding denials for appropriate and accurate coding. Review concurrent admissions and create documentation clarification queries requesting providers to provide additional documentation within the record. Functions as the liaison between the Coding staff, Physician Advisors and Providers. Communicates with and educates Physician Advisors and providers regarding areas of documentation improvement. Reports audit results to appropriate individuals, groups and committees on a monthly or as requested basis. Fosters relationships between all disciplines. Maintains current and thorough knowledge and understanding of clinical documentation improvement, Epic systems, coding schemes, APR-DRG groupers, Cooks policies, procedures, regulatory requirements and guidelines for documentation, coding and billing/reimbursement.

Education: Must have an Associates degree in Business or Clinical field (i.e. Nursing, Health Information Management, etc.). Masters Degree in health-related field desirable Must have a minimum of three (3) years current & continuous acute care hospital inpatient coding required for Coding Professionals. 1-2 years APR/DRG coding and clinical validation auditing experience in a pediatric setting highly desired. ICD-10-CM training highly preferred. 2 years acute nursing experience required for RNs. Pediatric ER or ICU nursing experience for RNs preferred. Certified Clinical Documentation Specialist (CCDS) credential and/or Certified Documentation Improvement Practitioner (CDIP) credential is preferred along with knowledge of ICD-10, and APR-DRGs. Will be required to obtain on or before the third-year hire date. Demonstrates superior coding expertise and critical thinking skills with the ability to solve problems appropriately using knowledge and current policies/procedures, guidelines and regulations. Technically competent and fluent knowledge in navigation of electronic medical record applications, coding decision support tools, including encoders, abstracting & billing systems, electronic medical records (used as coding source documents) and other associated computer applications required. Proficiency in computer assisted coding/CDI tools, automated coding work flow process and management of coded data integrity highly desired. Experience using Microsoft Office applications (excel, word, outlook, power point) required. Ability to remain focused, work well independently and productively with minimal guidance and without direct supervision. Must have sharp analytical and critical thinking skills, must be highly detail oriented, have strong organizational skills, writing, interpersonal and communication skills with ability to maintain confidentiality, create positive relationships; energetic, flexible, goal and team oriented. Strong verbal and written communication skills. Fluent English. Ability to give presentations. Ability to interact with providers and adapt to different communication styles. Ability to provide excellent customer service routinely in all types of interactions with all individuals. Demonstrated coding knowledge and proficiency is required with demonstrated ability to easily articulate knowledge of coding guidelines and procedures. Ability to work independently in a multi-task atmosphere, take initiative, use sound judgement, work with tight deadlines and be flexible, embrace change as this role encompasses a spectrum of highly specialized duties that are only performed by the immediate team members.

Certification/Licensure: Registered Health Information Administrator (RHIA) or Registered Health Information Technologist (RHIT) with Certified Coding Specialist (CCS) required. OR Registered Nurse (RN) with a current, valid, license to practice in Texas with Certified Coding Specialist (CCS) - highly desired. CDI experience highly desired. Certified Clinical Documentation Specialist (CCDS) highly desired. ICD-10-CM/PCS training highly desired. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) are required to be obtained on or before the third (3) year hire date.

About Us: Cook Children’s is an equal opportunity employer. As such, Cook Children’s offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination. Cook Children’s is a Texas-only employer. If you are hired, you will need to maintain your primary residence within the state of Texas, along with all licenses and credentials required for your position throughout your employment. Promise, a strong word with deep meaning that everyone understands—especially kids. This is the foundation of our organization and what drives us to blaze new trails in medical care, research, advanced technology, as well as programs and initiatives that benefit children who may not otherwise have access to quality health care. Every day our employees come to work with the intention of keeping our Promise. It's the guiding principle that helps our patients and their families get better and stay healthy. As a member of our Cook Children's team, you can be an important part of making that happen.