Clinical Documentation Auditor/Educator (Remote)

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.