Part-Time CDI Auditor: Drive Documentation Excellence

Wellstar Health System, Inc.; Athens (GA); On-site; USD 70,000 - 100,000; Full time

Job summary

Wellstar Health System, Inc. seeks a CDI Auditor to evaluate and improve the clinical documentation in patient records.

You will collaborate with the CDI team, providers, and coders to ensure documentation reflects severity of illness and level of service across hospital stays. The role requires minimum CDI experience in acute care, coding knowledge, and strong communication skills to educate staff and drive performance improvements.

Qualifications

• Minimum 2 years in acute care as a CDS required; 5 years healthcare experience required.
• Prior CDI/Coding auditor experience preferred; inpatient case management or utilization review preferred.
• Active coding/health information certifications: CCS, CPC, RHIA or RHIT preferred.
• RN license or nursing education required per role specifics.

Responsibilities

• Initiates audits and prepares findings for CDI Education Lead to support education.
• Audits medical records for opportunities related to documentation improvement, PSI, HACs, mortality.
• Performs real-time audits of reviews and provides feedback on queries and processes.
• Reviews data trends to identify additional improvement areas.
• Validates data in CDI software for accuracy in measuring physician and hospital outcomes.
• Acts as Super User for CDI software and related applications.
• Reviews documentation remotely during admissions to identify opportunities and communicate with physicians.
• Submits queries to clinicians to ensure complete and accurate records for post-discharge coding.
• Ensures queries are compliant, grammatically correct, and follow policies; escalates when needed.
• Provides follow-up education to CDI Education Lead and participates in departmental meetings.
• Maintains knowledge of coding/billing rules and regulatory requirements.

Skills

CDI auditing

Medical coding

Data analysis

Communication

Team collaboration

Problem solving

Education

Associates Nursing

Bachelors Health Science

Cert Clin Document Specialist

Registered Nurse (RN) or RHIA/RHIT preferred

Tools

Epic

3M 360 Encompass

encoder

Microsoft Word

Excel

PowerPoint

Job description

Wellstar Health System, Inc. seeks a CDI Auditor to evaluate and improve the clinical documentation in patient records.

You will collaborate with the CDI team, providers, and coders to ensure documentation reflects severity of illness and level of service across hospital stays. The role requires minimum CDI experience in acute care, coding knowledge, and strong communication skills to educate staff and drive performance improvements.