Clinical Documentation Specialist Auditor

About the position

The Clinical Documentation Specialist-Auditor plays a crucial role in enhancing the accuracy of clinical documentation and diagnostic coding practices. This position aims to improve the representation of patient complexity and severity of illness, ultimately impacting reimbursement and quality of care.

Responsibilities

• Review medical records documentation for reimbursement, severity of illness, and risk of mortality.
• Identify opportunities for improving the quality of medical record documentation.
• Confer with caregivers regarding additional documentation required using existing procedures.
• Collect statistics from reviews and maintain accurate records to document costs and benefits.
• Facilitate and enhance the coding and diagnosis-related group between physician and coding staff.

Requirements

• Bachelor's degree in a clinical field (e.g. RN, RRT, PT, OT, SLP, LCSW) from an accredited institution.
• Clinical license in the state of practice (e.g. RN, RRT, PT, OT, SLP, LCSW).
• Equivalent experience may substitute the degree requirement depending on clinical licensure.

Nice-to-haves

• Nursing experience as a Registered Nurse.
• Critical care nursing experience.
• Experience with Microsoft Office products.
• Clinical experience in ICU, CCU, primary care, or intermediate care.
• Experience with Clinical Documentation Integrity.
• Knowledge of iCentra and Help2 systems.

Benefits

• Comprehensive benefits package covering wellness programs.
• Support for living healthy, happy, secure, connected, and engaged.