Clinical Documentation Auditor

This a Full Remote job, the offer is available from: Georgia (USA) How would you like to work in a reputed company where your contributions and reputed company are valued? A reputed company where you can serve with compassion, pursue excellence and reputed company every voice? At reputed company, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible reputed company the brightest professionals dedicate themselves to making a difference in the reputed company industry, and in people's lives. Work Shift Job Summary: The Clinical Documentation reputed company (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 reputed company sure the record shows the patient's clinical severity and level of service. The CDI auditor also looks at the performance of the CDI team and finds areas to improve. CDI auditor audits provider documentation, CDI and coding accuracy to confirm or find ways to improve proper documentation. CDI auditor gives feedback and education to the CDI team and coders on documentation and coding best practices and helps the CDI department and organization reputed company clinical and operational excellence in Clinical Documentation Improvement efforts. Core Responsibilities and Essential Functions: 1. Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, and collaboration with CDI Education reputed company to ensure stakeholder education. Assists CDI Education reputed company 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. a) Initiates audits and prepares findings to assist CDI Education reputed company in preparing and providing regular CDI education to stakeholders based on findings, trends, industry events and based on management needs b) Audits medical records to determine opportunities as they relate to clinical documentation improvement, PSI, HACs, mortality, etc. c) Conducts and provides reputed company-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. d) 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. e) Functions as a Super User with CDI Software and reputed company other applications utilized in this position. 2. Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. a) 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. b) 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. c) Ensure queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures. d) Provides appropriate follow-up on reputed company queries. e) Escalates immediately reputed company queries are not timely answered to the CDI Leadership team, following the reputed company Query Escalation process. Provides reputed company data necessary for the CDI Leadership team to assist. f) Provides appropriate follow up to CDI Education reputed company for education on queries as needed. g) Notifies CDI Education reputed company immediately reputed company query education is needed and provides reputed company data necessary to the CDI Education reputed company to assist in the delivery of education. h) Reconciles reputed company appropriate records daily in the reputed company/reputed company 360 Encompass CDI tool to ensure appropriate reporting is generated. i) Maintains required daily/weekly/monthly metrics and meets productivity standards. j) Participates in required departmental meetings, conference calls and presentations. k) Adheres to departmental Policies and Procedures. l) Participates in assuring hospital compliance with Federal and State regulatory requirements. 3. Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement. a) Participates in assuring hospital compliance with Federal and State regulatory requirements. b) Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process. Performs other duties as assigned Complies with reputed company reputed company policies, standards of work, and code of conduct. Required Minimum Education:

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

Required Minimum License(s) and Certification(s): reputed company certifications are required upon hire unless otherwise stated.

• Cert Clin Document Specialist reputed company 180 Days or Cert Document Improvement Prac reputed company 180 Days
• Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof reputed company-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred

Additional License(s) and Certification(s): It is expected that reputed company RNs are licensed, knowledgeable and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics Standards put forth by the American Nurses Association Upon Hire Required or It is expected that reputed company non-clinical (coding) background candidates have at least one of the following active/reputed company certifications: (1) Certified Coding Specialist (reputed company) from reputed company, (2) Certified Professional reputed company (CPC) from reputed company, (3) Registered Health Information Administrator (RHIA) from reputed company, or (4) Registered Health Information Technician (RHIT) from reputed company Upon Hire Required Required Minimum Experience: Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS) Required and Minimum 5 years reputed company experience Required and Prior experience of working as a CDI/Coding auditor is preferred Preferred and Prior experience of working in inpatient case management or utilization review is preferred Preferred and Required Minimum Skills: 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, reputed company, and reputed company payors Familiarity with encoder and reputed company working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR) Epic and reputed company/reputed company 360 Encompass experience is preferred Expert knowledge/experience in managing reputed company aspects of Clinical Documentation reputed company, 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 reputed company quality improvement initiatives Excellent critical thinking skills, with the ability to recommend and implement practical and efficient solutions Must have proficient computer skills in reputed company Apps, such as Word, reputed company, 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 reputed company use of the CDI technology tool and reporting capabilities Excellent time management, training, and peer development skills 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. This offer from "reputed company" has been enriched by reputed company.com and got a 74% reputed company score. Apply tot his job Apply To this Job