Clinical Documentation Auditor

Wellstar Health SystemUnited States only

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How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, 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 when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

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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 make 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 achieve clinical and operational excellence in Clinical Documentation Improvement efforts. Core Responsibilities and Essential Functions:

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Clinical Documentation Auditor at Wellstar Health System · ApplyPick

Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, and collaboration with CDI Education Lead to ensure stakeholder education. Assists CDI Education Lead 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 Lead in preparing and providing regular CDI education to stakeholders based on findings, trends, industry events and based on management needsb)Audits medical records to determine opportunities as they relate to clinical documentation improvement, PSI, HACs, mortality, etc.c)Conducts and provides real-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 all 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 all queries.e)Escalates immediately when queries are not timely answered to the CDI Leadership team, following the Wellstar Query Escalation process. Provides all data necessary for the CDI Leadership team to assist.f)Provides appropriate follow up to CDI Education Lead for education on queries as needed.g)Notifies CDI Education Lead immediately when query education is needed and provides all data necessary to the CDI Education Lead to assist in the delivery of education.h)Reconciles all appropriate records daily in the Solventum/3M 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 assignedComplies with all Wellstar Health System policies, standards of work, and code of conduct. Required Minimum Education:

Clinical Documentation Auditor

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Job Summary:

Clinical Documentation Auditor

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Job Summary:

Required Minimum License(s) and Certification(s):

Additional License(s) and Certification(s):

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