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Clinical Documentation & Integrity Auditor/Educator (Remote)

extra parental leave

Remote:

Full Remote

Contract:

Full time

Experience:

Mid-level (2-5 years)

Work from:

United States

Offer summary

Qualifications:

Must have a Bachelor's of Nursing, but a Master’s Degree is preferred., Hold a valid State of Texas nursing license and a Certified Clinical Documentation Specialist (CCDS) certificate., Need at least 3-5 years of Clinical Documentation Specialist (CDS) experience with proficiency in MS Office and EMR systems..

Key responsabilities:

Audit and conduct case reviews to ensure quality compliance by CDIS.
Track and report audit findings, identify knowledge gaps, provide training to improve accuracy.
Stay updated with coding guidelines and conduct clinical quality audits.
Develop and update audit policies, procedures, and collaborate with leadership for post-discharge documentation audits.

Memorial Hermann Health System Health Care XLarge https://www.memorialhermann.org/

14227 - 14227 Employees

See more Memorial Hermann Health System offers

Job description

At Memorial Hermann, we pursue a common goal of delivering high quality, efficient care while creating exceptional experiences for every member of our community. When we say every member of our community, that includes our employees. We know that when our employees feel cared for, heard and valued, they are inspired to create moments that exceed expectations, while prioritizing safety, compassion, personalization and efficiency. If you want to advance your career and contribute to our vision of creating healthier communities, now and for generations to come, we want you to be a part of our team.

Job Summary

The Clinical Documentation Improvement (CDI) Auditor Educator will facilitate improvement system-wide in the overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation, education and data analysis. The incumbent will be responsible for identification of patterns, trends, and opportunities for the entire CDI team, at all acute care facilities, to improve accuracy and outcomes. This position will also be responsible for assisting with large retrospective audits, at the request of hospital clients system-wide, and for educating physicians, if needed. Reports to the CDI Quality/Education Manager. The CDI Auditor reports to the Director as an individual contributor and provides recommendations on clinical documentation quality improvement and education programs.

Job Description

**Applicants must meet all the following minimum qualifications to be considered for this position**

Minimum Qualifications

Education: Bachelor's of Nursing, 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 preferred

Experience / Knowledge / Skills:

Minimum of three (3) to five (5) years of CDS experience
Previous CDIS auditing and education experience and/or CDIS supervisory/management background preferred
Strong computer proficiency including working knowledge of MS Office- Word, Excel and Outlook and 3M Coding and Reimbursement software; experience with Cerner EMR preferred
Excellent communication, analytical and problem solving skills are essential
Strong organizational skills and must be detail oriented
Highly analytical with strong risk assessment, impact analysis and problem solving skills
Highly self-motivated, yet demonstrate ability to be a team player and take direction
Flexible and able to multi-task and prioritize work load on a daily basis, performing concurrent chart reviews as needed

Principal Accountabilities

Audits case reviews and queries of Clinical Documentation Specialists (CDIS) to ensure quality and compliance, using audit tools developed.
Tracks, trends, and reports audit findings for each Clinical Documentation Specialist (CDIS), Hospital Region, and System-wide to Director/management team.
Identifies knowledge gaps and provides clear explanations and interpretations on missing, unclear, conflicting, or non-compliant information captured by the CDIS.
Researches, investigates and remains up to date on both clinical and coding guidelines in quarterly Coding Clinics as they relate to physician documentation improvement needed, in an ICD-10 coding environment.
Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.
Develops presentation material and provides training and education to physicians and CDIS staff as needed in an effort to strengthen documentation practices and ensure accurate coding that reflects the severity of illness (SOI) and risk of mortality (ROM) of patients they serve.
Responsible for using audit tools to conduct clinical quality audits
Develops and updates policies and procedures around the CDIS audit function; and refines audit tools as needed in collaboration with Director/management team.
Collaborates with leadership to conduct focused post-discharge documentation and coding audits as requested by hospital clients system-wide.
Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.
Other duties as assigned.