Clinical Documentation Auditor

The Clinical Documentation Auditor will identify areas of improvement to fully, compliantly, and accurately reflect patient acuity through DRG assignment, severity of illness, risk of mortality and risk adjustment factors via primarily in-depth retrospective (post-discharge, prebill) audit of the patient's clinical record and related findings and queries performed by the Clinical Documentation Specialists. The CD Auditor will review results with management making recommendations for developing educational and process improvement plans to achieve departmental objectives and goals. The focus of these audits will be related to overall team effectiveness and individual performance. The CDI Auditor is considered to be a subject matter expert regarding basic and intermediate CDI and coding concepts. CD Auditor works collaboratively with and provides feedback related to review findings for clinical documentation, clinical validation and query opportunities to multidisciplinary teams. The CDI Auditor will work closely with management to provide the status of reviews and propose topics for and clinical documentation improvement opportunity/education needed. This position serves as the liaison between the Medical Staff, Quality and Health Information. 

Medical school graduate (MD, MBBS), Foreign Medical Graduate or Registered Nurse (RN) and Certified Clinical Documentation Specialist (CCDS), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT). Bachelor's degree required. Seven to Ten years of work experience.  Strong analytic, organizational and time management skills. Strong computer skills, working with Microsoft Office. Critical thinking and multi-tasking. Medical Terminology. Strong communication skills necessary to work with physicians.