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Wellstar Health System · 23 hours ago

Clinical Documentation Auditor

United States

Full-time

Remote

Mid, Senior Level

5+ years exp

Wellstar Health System is dedicated to enhancing the health and well-being of every person they serve. The Clinical Documentation Auditor evaluates the quality and accuracy of clinical documentation, collaborates with the CDI team, and provides education on best practices to improve documentation and coding compliance.

FitnessHealth Care

Responsibilities

Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, and collaboration with CDI Education Lead to ensure stakeholder education

Assists CDI Education Lead remotely with preparing provider education materials, gathering articles or other information for presentations and meetings

Performs staff, PSI, HAC, HAI, mortality, etc. reviews remotely as assigned by the management

Initiates audits and prepares findings to assist CDI Education Lead in preparing and providing regular CDI education to stakeholders based on findings, trends, industry events and based on management needs

Audits medical records to determine opportunities as they relate to clinical documentation improvement, PSI, HACs, mortality, etc

Conducts and provides real-time audits of reviews, queries and reports and provide feedback on process, query opportunities and query compliance

Reviews data and trends to identify additional areas of opportunity

Conducts Validation and Special Project tasks to support the CDI Leadership and ensure appropriate data is entered, captured, and reported in the CDI Software for the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes

Functions as a Super User with CDI Software and all other applications utilized in this position

Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician

Performs hospital-wide medical record reviews facilitating improvement in the quality, completeness, and accuracy of medical record documentation to ensure coding compliance, accurate reporting, and improved patient outcomes

Submits electronic queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post discharge that will accurately reflect the severity and risk of mortality of the patient population

Ensure queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures

Provides appropriate follow-up on all queries

Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process

Provides all data necessary for the CDI Leadership team to assist

Provides appropriate follow up to CDI Education Lead for education on queries as needed

Notifies CDI Education Lead immediately when query education is needed and provides all data necessary to the CDI Education Lead to assist in the delivery of education

Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated

Maintains required daily/weekly/monthly metrics and meets productivity standards

Participates in required departmental meetings, conference calls and presentations

Adheres to departmental Policies and Procedures

Participates in assuring hospital compliance with Federal and State regulatory requirements

Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement

Participates in assuring hospital compliance with Federal and State regulatory requirements

Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process

Performs other duties as assigned

Qualification

Clinical Documentation IntegrityCoding knowledgeCDI Software proficiencyData analysisCommunication skillsMicrosoft OfficeTime managementCollaborationCritical thinking

Required

Associates Nursing or Bachelors Health Science or Accredited Program Health Science or Doctorate Medicine

Cert Clin Document Specialist within 180 Days or Cert Document Improvement Prac within 180 Days

Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof Coder-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred

Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS)

Minimum 5 years healthcare experience

Strong understanding of disease processes, clinical indications and treatments; and provider documentation requirements to reflect severity of illness, risk of mortality and support the diagnosis/procedures performed for accurate clinical coding and billing according to the rules of Medicare, Medicaid, and commercial payors

Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)

Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, including CDI productivity, quality, education and training, compliance auditing, data analysis and trending, report management, performance improvement initiatives

CDI/Coding chart review experience required

Excellent communication skills, employing tact and effectiveness

Demonstrate effective communication skills and collaborates with medical staff, clinical departments, and key facility leadership team members

Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives

Excellent critical thinking skills, with the ability to recommend and implement practical and efficient solutions

Must have proficient computer skills in Microsoft Apps, such as Word, Excel, and PowerPoint, as well as CDI technology tools required for the job functions

Must be comfortable with doing data analysis, and preparing and maintaining records and written reports

Drives optimal use of the CDI technology tool and reporting capabilities

Excellent time management, training, and peer development skills