[Hiring] Clinical Chart Auditor @California Retina Consultants

Role Description

The Clinical Chart Auditor is responsible for conducting systematic reviews of patient medical records to ensure clinical documentation integrity and coding accuracy. This role is essential for minimizing audit risks, optimizing revenue cycle performance, and supporting regulatory adherence for retina-specific services. Remote work options may be available based on operational needs, candidate qualifications, and practice location requirements. This is a Remote position; however, all candidates considered for this position must currently reside within Central California.

Duties / Responsibilities

• Perform routine internal chart audits (retrospective, concurrent and prospective) on a representative sample of patient encounters.
• Verify alignment between clinical documentation, ICD-10 diagnoses, CPT/HCPCS procedure codes, and supporting elements (physician orders, informed consents, medical necessity, etc.).
• Identify, document, and track documentation deficiencies and compliance gaps (cloned notes, insufficient chief complaints, lack of medical necessity, unsupported level of the office visit CPT, etc.), generating detailed audit reports.
• Analyze audit findings to produce trended data on clinical documentation integrity accuracy rates and risk areas, presenting actionable insights to leadership, billing, and clinical teams for process improvements.
• Collaborate with clinical trainers, billing specialists, scribes and physicians to provide targeted feedback, resolve discrepancies, and deliver education on documentation standards, coding guidelines, and audit best practices.
• Monitor key performance indicators (KPIs) for clinical documentation integrity and coding accuracy, contributing to the practice's overall compliance program.
• Facilitate MIPS success by gathering and auditing required clinical data and collaborating with the clinical team to implement best practices.
• Manage prescription drug processes including handling Rx refills, processing prescription drug change requests, and facilitating prior authorizations (PAs) to support timely and accurate medication delivery in coordination with clinical teams.

Requirements

• Bachelor's degree preferred.
• Ophthalmic Scribe Certified (OSC) required.
• Ophthalmic Coding Specialist Retina (OCSR) required.
• CRT, COA, COT, COMT highly preferred.
• 2+ years of experience as a scribe in ophthalmology setting (retina subspecialty exposure preferred).
• 1+ years as a lead scribe and/or clinical trainer highly preferred.

Preferred Skills / Abilities

• Demonstrated knowledge of retina-specific documentation requirements.
• Proficiency with Nextech EHR and EPM systems.
• Knowledge of coding, HIPAA and other charting regulatory requirements.
• Proficiency with MS Office Tools (Word, Excel, Powerpoint, SharePoint, OneNote, OneDrive).
• Strong analytical, communication, and interpersonal skills.
• Ability to follow instructions, work well with others and alone with minimal supervision.
• Excellent organizational and problem-solving abilities.
• Ability to work effectively in a fast-paced and dynamic environment.
• Ability to handle conflict resolution and hold staff accountable.