Clinical Documentation Audit Specialist

About This Role

Clinical Documentation Audit Specialist provides expert-level reviews of targeted medical records to ensure accurate quality data reporting and provides educational feedback to CDI managers. This position supports organizational goals by identifying opportunities to partner with providers to accurately capture patients' clinical pictures, participating in enterprise-wide performance improvement efforts, and demonstrating a commitment to teamwork and cooperation.

Responsibilities

• Interact with co-workers, visitors, and other staff consistent with the values of Jefferson
• Accurately review designated medical records for completeness in documentation of diagnostic and procedural information in compliance with Center for Medicare Services (CMS), Department of Health regulatory, and financial requirements
• Provide an expert level review of targeted medical records to ensure accurate data capture of patient diagnoses and procedures
• Perform second level reviews on designated records (i.e., mortality, Patient Safety Indicator reviews, sepsis, etc.) to ensure accurate quality reporting and serve as department liaison for quality related meetings
• Prepare well-written and compliant queries to communicate with physicians and other providers regarding clarifying conflicting, missing, or incomplete documentation in the medical record
• Support revenue cycle initiatives in managing the load of cases that are discharged but not final billed by supporting timely CDI query follow-up in accordance with query escalation process
• Coordinate with management to utilize expert level CDI skills to conduct quarterly quality record review audits of CDI specialists across the enterprise
• Assist with enterprise-wide documentation improvement quality initiatives
• Evaluate opportunities for CDI education and/or CDI workflow and process improvements
• Participate on hospital committees to conduct record review studies, as necessary, to facilitate improvement in clinical documentation processes to ensure overall quality, completeness, and compliance

Requirements

• Strong working knowledge and experience in clinical record reviews, 3M encoder coding systems, Diagnostic Related Group (DRG) system, and Epic EHR system
• Expert level working knowledge of ICD-10 diagnosis and procedural coding conventions and severity of illness/risk of mortality
• Excellent interpersonal and communication skills (both written and verbal) with previous experience working collaboratively within teams
• Ability to work remotely and manage participation in multiple committees
• Strong working knowledge of Microsoft Office; Outlook, Word, Excel, PowerPoint
• Education: Bachelor of Science in Nursing, Medical Graduate degree, or Bachelor's Degree in Health Information Management or other related field or 4 years related clinical experience in lieu of bachelor's degree