Clinical Documentation Specialist Audit and Education

Ascension; St. Louis (MO); Remote; USD 65,000 - 95,000; Full time

Benefits offered by this job

Health coverage

Tuition reimbursement

PTO and holidays

Career growth

Job summary

Ascension is seeking a CDI professional to help ensure accuracy and compliance of clinical documentation while supporting the education of front-line staff. This remote-friendly role emphasizes collaboration with the CDI team and provider education to enhance documentation practices.

You will perform audits, maintain tools, track metrics, and present findings to leadership, applying ICD-10-CM/PCS, CMS rules, and DRG knowledge to drive quality and compliance.

Qualifications

• CCDS certification preferred or required per policy.
• CDI knowledge and auditing experience.
• Experience creating education content for diverse audiences.

Responsibilities

• Assess accuracy, consistency, and compliance of clinical documentation reviews.
• Perform routine and ad hoc audits of CDI queries and EHR entries.
• Maintain internal audit tools and track performance metrics.
• Evaluate query appropriateness, clinical evidence, and coding rules.
• Create and maintain educational materials and templates.

Skills

CDI knowledge

Auditing

Education content

Education

Associate/Bachelor's degree

4 years of applicable experience

Tools

Epic EHR

3M CDI

Nuance CDI

Iodine

Job description

• Department: Clinical Documentation Integrity
• Schedule: Full-Time | Days | Monday-Friday

• Location: Remote
• Department: Clinical Documentation Integrity
• Schedule: Full-Time | Days | Monday-Friday

How you’ll make an impact in this role

• Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.
• Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
• Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis.
• Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS). Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
• Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.

What Minimum Requirements You’ll Need

Licensure / Certification / Registration:

Required Credential(s)

• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.

Education

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Additional Preferences

• Must have a Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)
• Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.
• Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
• Proven ability to develop engaging education content tailored to diverse audiences (clinical, coding, administrative).
• Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).

Benefits that help you thrive

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options
• Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance
• Time to recharge: pro-rated paid time off (PTO) and holidays
• Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning
• Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources
• Family support: parental leave, adoption assistance and family benefits
• Other benefits: optional legal and pet insurance, transportation savings and more

Life at Ascension: Where purpose meets opportunity

Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you'll find an inclusive and supportive environment where your contributions truly matter.

Equal employment opportunity employer

Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.