Clinical Documentation Auditor

The Clinical Documentation Auditor will identify areas of improvement to fully, compliantly, and accurately reflect patient acuity through DRG assignment, severity of illness, risk of mortality and risk adjustment factors via primarily in-depth retrospective (post-discharge, prebill) audit of the patient's clinical record and related findings and queries performed by the Clinical Documentation Specialists. The CD Auditor will review results with management making recommendations for developing educational and process improvement plans to achieve departmental objectives and goals. The focus of these audits will be related to overall team effectiveness and individual performance. The CD Auditor is considered to be a subject matter expert regarding patient safety indicators (PSIs) along with basic CDI and coding concepts. CD Auditor works collaboratively with and provides feedback related to review findings for clinical documentation, clinical validation and query opportunities to multidisciplinary teams. The CD Auditor will work closely with management to provide the status of reviews and propose topics for and clinical documentation improvement opportunity/education needed. This position serves as the liaison between the Medical Staff, Quality and Health Information.

Bachelor's degree required, and seven to ten years of work experience required. Medical school graduate (MD, MBBS), Foreign Medical Graduate or Registered Nurse (RN) Required. Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), Certified Documentation Integrity Practitioner (CDIP), Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) Preferred. Strong analytic, organizational and time management skills. Strong computer skills, working with Microsoft Office. Critical thinking and multi-tasking. Medical Terminology. Strong communication skills necessary to work with physicians.