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.
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.
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.
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)
