Clinical Documentation Auditor/Educator - Remote | Wfh

We have an exciting opportunity for an experienced Clinical Documentation Improvement (CDI) Auditor Educator! In this role, you will play a vital part in enhancing the overall quality, accuracy, and completeness of medical record documentation. Through extensive audit investigations, education initiatives, and data analysis, you will help identify patterns, trends, and opportunities for improvement across our entire CDI team in all our acute care facilities. You will also have the chance to contribute to large retrospective audits for our hospital clients upon request, while providing education to physicians when necessary. As a key member of our CDI department, you will report to the CDI Quality/Education Manager and provide valuable recommendations on clinical documentation quality improvement and educational programs.

Remote Work Opportunity! Join our team of passionate Clinical Documentation Auditors/Educators and enjoy the flexibility of working from home! We are specifically looking for individuals residing in the following states: Texas, Louisiana, Oklahoma, Nebraska, Florida, Georgia, Tennessee, and South Carolina.
Education
Minimum Qualifications:
Bachelor's of Nursing (BSN) degree is required.
Master's Degree in Nursing or Management preferred.
Licenses/Certifications
Current State of Texas license or temporary/compact license to practice professional nursing.
Certified Clinical Documentation Specialist (CCDS) required.
AHIMA ICD-10-CM/PCS Trainer certification preferred.
Experience/Knowledge/Skills
Minimum of three (3) to five (5) years of experience as a Clinical Documentation Specialist (CDS).
Previous experience in CDIS auditing, education, or supervisory/management roles is highly desired.
Strong computer proficiency, including MS Office (Word, Excel, Outlook), 3M Coding and Reimbursement software, and familiarity with Cerner EMR.
Excellent Communication, Analytical, And Problem-solving Skills Are Essential.
Strong organizational skills with a keen eye for detail.
Highly self-motivated and able to work independently while also being a collaborative team player.
Flexible and adept at multitasking, prioritizing workload, and performing concurrent chart reviews as required.
Demonstrates commitment to the Partners-in-Caring process, embodying our values of innovation, accountability, empowerment, collaboration, compassion, and results, while ensuring exceptional patient care.
Principal Accountabilities
Conduct audits of Clinical Documentation Specialists (CDIS) case reviews and queries to ensure quality and compliance, utilizing developed audit tools.
Track, analyze, and report audit findings for each CDIS, Hospital Region, and System-wide to the Director and management team.
Identify knowledge gaps and provide clear explanations and interpretations for missing, unclear, conflicting, or non-compliant information captured by the CDIS.
Stay up-to-date on clinical and coding guidelines, particularly in an ICD-10 coding environment, by researching and investigating quarterly Coding Clinics related to necessary physician documentation improvement.
Assist in maintaining the quality, timeliness, and completeness of the health record, ensuring accurate data, effective provider communication, and positive quality outcomes. Act as a resource for appropriate clinical documentation.
Develop presentation materials and deliver training and education sessions to physicians and CDIS staff, strengthening documentation practices and ensuring accurate coding that reflects the severity of illness (SOI) and risk of mortality (ROM) of patients.
Utilize audit tools to perform clinical quality audits.
Collaborate with leadership to conduct focused post-discharge documentation and coding audits as requested by our hospital clients system-wide.
Contribute to the development and refinement of policies, procedures, and audit tools for the CDIS audit function in collaboration with the Director and management team.
Employment Type: Full-Time
Salary: $ 111,902.00 Per Year