Senior Clinical Documentation Auditor & CDS Educator

University of Southern California; Los Angeles (CA); On-site; USD 92,000 - 151,000; Full time

Job summary

The Senior Clinical Documentation Specialist - Auditor (CDS) at USC Keck Hospital reviews inpatient medical records to accurately reflect severity, mortality risk, LOS, and hospital quality metrics. Proficient in ICD10-CM/PCS coding guidelines and IPPS documentation requirements, the role leads CDI team activities and collaborates with physicians and clinical staff.

You will monitor CDI metrics, perform retrospective reviews, support denial management, and educate CDS and coders.

Qualifications

• Bachelor's degree required.
• Registered nurse license in California or foreign medical graduate required.
• 3 years CDI experience required.
• 3 years clinical experience in an acute care setting required.

Responsibilities

• Directs and educates physicians and staff on CDI goals.
• Supports day-to-day team operations and trains new staff.
• Leads clinical denial/appeal processes and clinical validations.
• Performs audits for denial prevention and quality metrics.
• Improves documentation through physician query generation and education.
• Achieves high physician response rates and escalates queries when needed.
• Identifies opportunities to improve documentation through queries.
• Uses MEAT framework for compliant, non-leading queries.
• Applies evidence-based criteria for clinical validation of diagnoses.
• Uses CDI software to track metrics and ensure data integrity and communication.

Skills

CDI experience

Acute care experience

Education

Bachelor's degree

RN license or foreign medical graduate

CCDS/CDIP certification preferred

Job description

The Senior Clinical Documentation Specialist - Auditor (CDS) at USC Keck Hospital reviews inpatient medical records to accurately reflect severity, mortality risk, LOS, and hospital quality metrics. Proficient in ICD10-CM/PCS coding guidelines and IPPS documentation requirements, the role leads CDI team activities and collaborates with physicians and clinical staff.

You will monitor CDI metrics, perform retrospective reviews, support denial management, and educate CDS and coders.