Clinical Documentation Integrity Specialist

Cook Children's Health Care System; Fort Worth (TX); On-site; USD 85,000 - 105,000; Full time

Job summary

Cook Children’s Health Care System is seeking a Clinical Documentation Integrity Auditor to perform chart reviews focused on documentation accuracy, coding accuracy, and APR-DRG assignment compliance. The role analyzes care documentation after coding and before billing, verifies POA and DRG alignment, and conducts pre-bill audits with trend reporting.

The candidate will educate providers and coders on documentation improvements, review denials, and liaise with Physician Advisors to ensure

Qualifications

• Associate degree in Business or Clinical field required; Masters desirable.
• Minimum three years acute care inpatient coding experience.
• 1–2 years APR/DRG coding and clinical validation auditing in pediatrics is preferred.
• RN with pediatric nursing experience acceptable with CCS.
• RHIA/RHIT or CCS credentials preferred; CCDS/CDIP desired by third year.

Responsibilities

• Perform chart reviews for documentation accuracy and APR-DRG assignment.
• Analyze Present On Admission (POA) status and DRG to ensure code specificity.
• Conduct Pre-bill Audit (PBA) reviews and report findings monthly.
• Provide feedback and education to providers and coders on documentation improvement.
• Review payor coding denials for accuracy and completeness.
• Act as liaison between Coding staff, Physician Advisors and Providers.
• Maintain knowledge of CDI, ICD-10, APR-DRGs, and Epic systems.

Skills

ICD coding

DRG assignment

POA knowledge

Auditing

Epic systems

Documentation accuracy

Communication

Attention to detail

HIPAA compliance

Education

Associate degree in Business or Clinical field

Masters degree desirable

RHIA/RHIT with CCS preferred

CCDS/CDIP desired

Tools

Encoders

Billing systems

MS Office (Excel/Word/PowerPoint)

Epic systems

Job description

Cook Children’s Health Care System is seeking a Clinical Documentation Integrity Auditor to perform chart reviews focused on documentation accuracy, coding accuracy, and APR-DRG assignment compliance. The role analyzes care documentation after coding and before billing, verifies POA and DRG alignment, and conducts pre-bill audits with trend reporting.

The candidate will educate providers and coders on documentation improvements, review denials, and liaise with Physician Advisors to ensure