Clinical Documentation Integrity (CDI) Auditor

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

Job summary

Cook Children's seeks a Clinical Documentation Integrity Auditor to review chart documentation for accuracy, support APR-DRG assignments, and ensure POA and coding compliance. The role includes pre-bill audits, education for providers, and liaising with physicians and coding staff.

Requirements include 3+ years inpatient coding experience, RN or RHIA/RHIT with CCS, and CDI tool proficiency. Networking with physicians and adherence to regulatory guidelines are essential for success.

Qualifications

• Associates degree in Business or Clinical field.
• Master’s Degree in health-related field desirable.
• Minimum 3 years acute care hospital inpatient coding experience.
• 2 years acute nursing experience; pediatric ER/ICU preferred.
• RHIA or RHIT with CCS preferred; RN with CCS highly desired.
• CCDS or CDIP certification required by year 3.
• ICD-10-CM/PCS training preferred.
• Proficient in Microsoft Office and CDI tools.
• Ability to work independently and maintain confidentiality.

Responsibilities

• Perform chart reviews related to documentation accuracy and coding accuracy and APR DRG assignment compliance.
• Analyze POA status and DRG accuracy for billing support.
• Conduct Pre-bill Audit (PBA) reviews and report results.
• Provide feedback and education to providers and coders on documentation improvement.
• Liaise between Coding staff, Physician Advisors and Providers.
• Review payor coding denials for accuracy; manage concurrent admissions and clarification queries.

Skills

Coding expertise

Critical thinking

Attention to detail

Communication skills

Presentation skills

Independent work

Customer service

Microsoft Office

Epic Systems navigation

Education

Associates degree in Business or Clinical field

Masters degree in health-related field

Tools

Epic Systems

Encoders / coding tools

Billing systems

Job description

## Clinical Documentation Integrity (CDI) AuditorApply: Fort Worth, TX: Full time: Posted Today: JR-119599**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 & APR DRG 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.