Clinical Documentation Auditor
Wellstar Health System
Summary
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.
Job description
Job Summary
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
- 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.
- 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 needs.
- Audits medical records to determine opportunities as they relate to clinical documentation improvement, PSI, HACs, mortality, etc.
- 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.
- 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.
- Functions as a Super User with CDI Software and all other applications utilized in this position.
- Reviews clinical documentation remotely during patient admissions to determine opportunities to improve physician documentation and communicates identified opportunities to the physician.
- 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.
- 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.
- Ensure queries are compliant, grammatically correct, concise, and free of typographical errors, and follow organizational query policies and procedures.
- Provides appropriate follow-up on all queries.
- 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.
- Provides appropriate follow up to CDI Education Lead for education on queries as needed.
- 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.
- Reconciles all appropriate records daily in the Solventum/3M 360 Encompass CDI tool to ensure appropriate reporting is generated.
- Maintains required daily/weekly/monthly metrics and meets productivity standards.
- Participates in required departmental meetings, conference calls and presentations.
- Adheres to departmental Policies and Procedures.
- Participates in assuring hospital compliance with Federal and State regulatory requirements.
- Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
- Reviews quarterly Coding Clinic changes/summaries and follows appropriate required changes to their process.
Requirements
- Associates Nursing or Bachelors Health Science or Accredited Program Health Science or Doctorate Medicine
- Cert Clin Document Specialist within 180 Days or Cert Document Improvement Prac within 180 Days
- Reg Nurse (Single State)-Preferred or RN - Multi-state Compact-Preferred or Cert Coding Spec-Preferred or Cert Prof Coder-Preferred or Reg Health Information Admin-Preferred or Reg Health Information Tech-Preferred
- For non-clinical (coding) background candidates: at least one of CCS, CPC, RHIA, or RHIT certification upon hire
- Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist (CDS)
- Minimum 5 years healthcare experience
- Prior experience of working as a CDI/Coding auditor is preferred
- Prior experience of working in inpatient case management or utilization review is preferred
- 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, Medicaid, and commercial payors
- Familiarity with encoder and current working knowledge of Coding Clinic Guidelines and federal updates to DRG system (MS and APR)
- Epic and Solventum/3M 360 Encompass experience is preferred
- Expert knowledge/experience in managing all aspects of Clinical Documentation Integrity, 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 continuous quality improvement initiatives
- Excellent critical thinking skills, with the ability to recommend and implement practical and efficient solutions
- Must have proficient computer skills in Microsoft Apps, such as Word, Excel, 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 optimal use of the CDI technology tool and reporting capabilities
- Excellent time management, training, and peer development skills
Company overview
Wellstar Health System is one of Georgia's largest and most comprehensive integrated healthcare systems, founded in 1993 and headquartered in Marietta, Georgia. As a non-profit health system, Wellstar operates with a mission to enhance the health and well-being of every person it serves through its PeopleCare approach. The system employs approximately 29,469 to 33,000 team members across multiple hospitals, health parks, medical offices, outpatient centers, pediatric centers, nursing facilities, and hospice and home care services. Wellstar is nationally recognized for operating Georgia's largest integrated trauma network and features the second-largest Emergency Department in the United States. The organization provides more than $1 billion annually in charity care and community programs, demonstrating its commitment to community health. Wellstar has earned numerous accolades including recognition on Fortune's 100 Best Companies to Work For, Best Workplaces in Health Care, and PEOPLE Companies that Care lists. The system embraces innovation through its venture firm Catalyst by Wellstar, which nurtures early-stage healthcare companies, and maintains academic partnerships with institutions like the Medical College of Georgia for caregiver training. With specialties spanning cardiovascular care, oncology, women's health, pediatrics, musculoskeletal services, and numerous other medical disciplines, Wellstar delivers comprehensive healthcare across all stages of life.