[Hiring] Clinical Documentation Auditor @1000 Wellstar Health System, Inc.

Role Description

The Clinical Documentation Integrity (CDI) Auditor must be good at problem-solving, clinical and coding knowledge, and communicating and collaborating. The CDI Auditor evaluates the quality and accuracy of the clinical documentation in the patient record, and works with the CDI team, providers, and coders to ensure the record reflects the patient's clinical severity and level of service. The CDI auditor also assesses the performance of the CDI team and identifies areas for improvement.

• Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics.
• Collaborates with CDI Education Lead to ensure stakeholder education.
• Assists CDI Education Lead with preparing provider education materials and gathering information for presentations.
• Performs staff, PSI, HAC, HAI, mortality reviews remotely as assigned by management.
• Initiates audits and prepares findings to assist in regular CDI education.
• Conducts and provides real-time audits of reviews, queries, and reports.
• Conducts Validation and Special Project tasks to support CDI Leadership.
• Functions as a Super User with CDI Software and other applications.
• Reviews clinical documentation remotely during patient admissions.
• Submits electronic queries to clinicians to ensure accurate documentation.
• Ensures queries are compliant and follows organizational policies.
• Provides follow-up on all queries and escalates issues as necessary.
• Maintains required daily/weekly/monthly metrics and meets productivity standards.
• Participates in departmental meetings, conference calls, and presentations.
• Adheres to departmental Policies and Procedures.
• Maintains knowledge of coding and billing rules and regulations.

Qualifications

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

Requirements

• All certifications are required upon hire unless otherwise stated.
• 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.
• It is expected that all RNs are licensed and knowledgeable as per the Scope of Practice and Code of Ethics Standards.
• It is expected that all non-clinical (coding) background candidates have at least one of the following active/current certifications: (1) Certified Coding Specialist (CCS) from AHIMA, (2) Certified Professional Coder (CPC) from AAPC, (3) Registered Health Information Administrator (RHIA) from AHIMA, or (4) Registered Health Information Technician (RHIT) from AHIMA.
• Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required.
• Minimum 5 years healthcare experience Required.
• Prior experience of working as a CDI/Coding auditor is preferred.
• Prior experience of working in inpatient case management or utilization review is preferred.

Skills

• Strong understanding of disease processes and provider documentation requirements.
• Familiarity with encoder and current working knowledge of Coding Clinic Guidelines.
• Epic and Solventum/3M 360 Encompass experience is preferred.
• Expert knowledge in managing all aspects of Clinical Documentation Integrity.
• CDI/Coding chart review experience required.
• Excellent communication skills and ability to collaborate with medical staff.
• Ability to interpret and apply guidelines and procedures.
• Excellent critical thinking skills.
• Proficient computer skills in Microsoft Apps and CDI technology tools.
• Comfortable with data analysis and maintaining records.
• Excellent time management, training, and peer development skills.

Benefits

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.