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UNC Health · 5 hours ago

Clinical Documentation Specialist Auditor - HIM Coding & CDI Quality

United States

Full-time

Remote

Mid Level

$35.52/hr - $51.05/hr

3+ years exp

UNC Health is an inclusive organization with a mission to improve the health and well-being of the communities they serve. The Clinical Documentation Specialist Auditor trains and audits Clinical Documentation Specialists across various entities, ensuring documentation accuracy and compliance while providing education and support to staff and physicians.

Addiction TreatmentHealth CareHealth DiagnosticsHospitalNon ProfitWellness

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

Qualification

ICD-10-CM codingICD-10-PCS codingCPT codingCDI documentation processesAHIMA certificationAAPC certificationRN licenseLPN licenseAdvanced Practice Provider licenseMedical Doctor licenseSound judgementCommunication skillsOrganizational skillsTime managementPresentation skillsCritical thinking

Required

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