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Clinical Documentation Integrity Auditor

Professional Credit Service -
Remote

Quick Apply

Job Details

Full-time
$45 - $58 an hour
11 days ago

Benefits

Health insurance
Dental insurance
Flexible spending account
Paid time off
Vision insurance
401(k) matching
Flexible schedule

Qualifications

Collaborate with healthcare professionals
Inpatient experience
Electronic health records (EHR) management
Health education for healthcare providers
Spreadsheets
Writing skills
CMS
Healthcare documentation compliance audits
Acute care facility experience
CMS regulatory compliance
Clinical staff training
Retrospective medical coding audits
Bachelor's degree
Health insurance knowledge
Medicare regulations
Clinical training
Continuous clinical improvement initiatives
Health information regulatory compliance
Data interpretation
Centers for Medicare & Medicaid Services (CMS) billing regulations
Health information management
Quality audits
Clinical documentation standards
Medical terminology

Full Job Description

The Clinical Documentation Improvement (CDI) Auditor is responsible for evaluating the quality, accuracy, completeness, and compliance of clinical documentation and CDI review processes. This role performs audits of inpatient medical records, CDI queries, and documentation practices to ensure accurate code assignment, compliant reimbursement, quality reporting, and regulatory compliance.

The CDI Auditor partners with CDI Specialists, Coding professionals, physicians, and operational leadership to identify documentation improvement opportunities, validate CDI program effectiveness, educate staff, and support continuous quality improvement initiatives.

If you’re looking for a career where your skills are valued and your work makes a difference, you’ll find your place at Ensource.

Essential Responsibilities

Perform audits of CDI reviews, medical records, and provider queries to evaluate the accuracy, completeness, and consistency of CDI specialists' work.
Assess CDI specialists' documentation review practices, query opportunities, and compliance with organizational policies and industry standards.
Provide individualized coaching, mentoring, and education to CDI Specialists based on audit findings to improve clinical judgment, documentation review techniques, query writing, and overall performance.
Serve as the CDI department's subject matter expert by educating staff on MS-DRGs, APR-DRGs, ICD-10-CM/PCS, Severity of Illness (SOI), Risk of Mortality (ROM), clinical validation, and compliant physician query practices.
Evaluate provider queries for clinical accuracy, compliance, and effectiveness, ensuring adherence to AHIMA, ACDIS, and organizational guidelines.
Validate accurate capture of diagnoses, procedures, CCs, MCCs, and other documentation impacting reimbursement, quality measures, and regulatory reporting.
Maintain current knowledge of CMS regulations, coding guidelines, CDI best practices, and emerging industry trends to ensure the CDI program remains compliant and effective.

Qualifications

Minimum of five (5) years of Clinical Documentation Improvement (CDI) experience in a large acute care hospital setting.
Minimum of three (3) years conducting CDI quality reviews, audits, or performance improvement initiatives.
Strong knowledge of:
- ICD-10-CM/PCS
- MS-DRG and APR-DRG methodologies
- Severity of Illness (SOI) and Risk of Mortality (ROM)
- Compliant Query Writing
- Hospital-Acquired Conditions (HACs)
- Clinical validation principles
- CMS regulations
- Documentation compliance standards
Experience reviewing concurrent and retrospective CDI cases.
Strong analytical, critical thinking, and problem-solving skills.
Excellent written and verbal communication skills.
Ability to educate CDI specialists, coders, and operational leadership.
Proficiency with Electronic Health Records (EHRs), CDI software, Microsoft Excel, and reporting tools.

Candidates should possess one or more of the following certifications:

Certified Clinical Documentation Specialist (CCDS)
Certified Documentation Improvement Practitioner (CDIP)
Certified Coding Specialist (CCS)
Certified Professional Coder (CPC)
Registered Health Information Administrator (RHIA)
Registered Health Information Technician (RHIT)

Why work with us?

THERE ARE MANY BENEFITS TO WORKING AT Ensource, INCLUDING:

Full-time, Part-time & PRN positions
Health Insurance (medical, dental, vision), Flexible Spending Account, & Aflac Group Products
Volunteer ReachOut Program: 40 Hours of Paid Time to Volunteer
401(k)/Roth with Company Match
Healthy Work-Life Balance
Collaborative Work Environment
Flexible Work Schedule
PTO for Full & Part-Time Employees
Employee Incentive Reward Program
Annual Stipend for Professional Certifications and Memberships (for Medical Coding Employees)

Travel: 0% No Travel Anticipated

Pay Range: $48-$58 Hourly

Required Education:

Bachelor's degree in Health Information Management, Nursing, or a related field.

Required Experience:

Minimum of 3 years of experience in clinical documentation improvement or a similar role in a healthcare setting.
Demonstrated experience working with electronic health records (EHR) systems.
Proven track record of collaborating with healthcare professionals to enhance documentation quality.

Required Skills and Abilities:

Strong understanding of medical terminology, coding systems (such as ICD-10, CPT), and healthcare regulations.
Excellent analytical skills with the ability to interpret complex clinical data.
Proficient in using clinical documentation software and tools.
Exceptional communication and interpersonal skills to effectively interact with medical staff and administrative personnel.
Ability to conduct training sessions and provide guidance to healthcare providers on documentation best practices.
Detail-oriented with strong organizational skills to manage multiple projects and deadlines efficiently.

Quick Apply

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Candidates should possess one or more of the following certifications:

THERE ARE MANY BENEFITS TO WORKING AT Ensource, INCLUDING:

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