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Clinical Documentation Specialist Auditor- HIM Coding & CDI Quality
UNC Health
Chapel Hill (NC)
Remote
USD 60,000 - 80,000
Full time
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Job summary
Join a forward-thinking organization dedicated to improving community health. As a Clinical Documentation Specialist Auditor, you'll play a key role in training and auditing documentation specialists across various entities. This exciting position involves traveling to clinics, providing hands-on support, and ensuring compliance with coding guidelines. You'll collaborate with physicians and clinical staff to enhance documentation practices, ultimately impacting patient care quality. If you're passionate about healthcare and eager to make a difference, this role offers a unique opportunity to grow within a supportive team environment.
Qualifications
- 3+ years of experience in Clinical Documentation Specialist roles.
- Strong knowledge of coding guidelines and compliance regulations.
Responsibilities
- Audit CDS for accuracy and provide education based on results.
- Analyze medical records to ensure compliance and accuracy.
- Educate staff on documentation practices and coding.
Skills
Education
Job description
Join to apply for the Clinical Documentation Specialist Auditor- HIM Coding & CDI Quality role at UNC Health
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Join to apply for the Clinical Documentation Specialist Auditor- HIM Coding & CDI Quality role at UNC Health
Description
Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.
Description
Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.
Summary
This positon trains and audits Inpatient and Outpatient Clinical Documentation Specialists (CDS) across all HCS entities that are owned or managed that have opted into shared services. This position reports to the HCS Supervisor Coding and CDI Quality and Training. This position may travel from entity to entity across the state to train and shadow round with Clinical Documentation Specialists. The CDS auditor provides elbow to elbow support during training and education as well as through webex. This position may travel to clinics and work with physicians and CDS on documentation education and issues for optimizing HCCs.
Responsibilities
- Audits CDS to assure a minimum of 95% accuracy and recommends education and training related to results.
- Monitor and provide feedback to new-hire CDS, as they progress through and complete the CDS training modules.
- Provides ongoing documentation and coding education to CDI Physician Advisers and CDS staff.
- Provides input to the CDS's performance evaluation completed and conducted by the Supervisor.
- Participates in the hiring and selection of new CDS with the hiring manager as requested.
- Analyzes and audits medical records concurrently to ensure that the clinical information within the medical record is accurate, complete, and compliant.
- Educates CDS, physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories and complexity of care rendered to all patients. Educates on proper creation of provider compliant queries.
- Ensures compliance with third party and State and Federal regulations.
- Audits CDS medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality. Assures accurate assignment of Working MS-DRG, ICD-10-CM/PCS codes and CPT codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations.
- Identifies cases for CDI Physician Advisor intervention and coordinates the CDI Physician Advisor scheduling, reviews and educational opportunities with residents, faculty, Advanced Practice Professionals (APP).
- Collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits and ROI.
- Assists with overseeing the quarterly CDI Physician Advisor meetings to discuss the status of the program and generates the dashboard reports for review and discussion.
- Conducts with the assistance/input of the appropriate CDS, educational sessions for physicians, CDI Physician Advisors, and coding staff as well as the CDS staff.
Other information:
Education Requirements
- Associate's degree in Health Information Management, Nursing or related field.
- Successful completion of the Clinical Documentation Specialist Proficiency Test.
- Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license with applicable credential
- Three (3) years of CDS experience
- Strong knowledge of ICD-10-CM, ICD-10-PCS, and CPT coding, MS DRG, hierarchical condition categories (HCC), and CDI documentation processes. Ability to interpret federal and state regulations as they relate to coding and compliance. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills. Strong critical thinking and sound judgement in decision making.
Legal Employer: NCHEALTH
Entity: Shared Services
Organization Unit: HIM Coding & CDI Quality
Work Type: Full Time
Standard Hours Per Week: 40.00
Salary Range: $35.52 - $51.05 per hour (Hiring Range)
Pay offers are determined by experience and internal equity
Work Assignment Type: Remote
Work Schedule: Day Job
Location of Job: US:NC:Chapel Hill
Exempt From Overtime: Exempt: Yes
This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job.
Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
- Seniority levelMid-Senior level
- Employment typeFull-time
- Job functionAccounting/Auditing and Finance
- IndustriesWellness and Fitness Services, Hospitals and Health Care, and Medical Practices
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