Clinical Documentation & Integrity Auditor/Educator - Remote | WFH - Get It Recruit - Healthcare
Houston, TX 77024
About the Job
We are seeking a passionate and detail-oriented Clinical Documentation Improvement (CDI) Auditor Educator to join our dynamic team. In this role, you will play a pivotal part in enhancing the quality, completeness, and accuracy of medical record documentation across our entire system. Through thorough audit investigations, education initiatives, and insightful data analysis, you will contribute to improving outcomes and ensuring excellence in patient care. Reporting to the CDI Quality/Education Manager, you will collaborate closely with our dedicated team of professionals, providing valuable insights and recommendations for enhancing clinical documentation practices.
Job Description
Minimum Qualifications
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 Clinical Documentation Specialist (CDS) experience
Previous experience in CDIS auditing, education, and/or supervisory/management roles preferred
Strong proficiency in computer applications including MS Office (Word, Excel, Outlook) and 3M Coding and Reimbursement software; experience with Cerner EMR preferred
Excellent communication, analytical, and problem-solving skills
Exceptional organizational skills with keen attention to detail
Self-motivated with the ability to work both independently and collaboratively within a team
Flexible with excellent multitasking abilities and the capacity to prioritize tasks effectively
Principal Accountabilities
Conduct audits of case reviews and queries performed by Clinical Documentation Specialists (CDIS) to ensure quality and compliance
Track, analyze, and report audit findings to management, identifying trends and opportunities for improvement
Provide clear explanations and interpretations on missing, unclear, or non-compliant information captured by CDIS, addressing knowledge gaps as needed
Stay updated on clinical and coding guidelines, particularly in an ICD-10 coding environment, to facilitate physician documentation improvement
Develop and deliver training and education sessions for physicians and CDIS staff to strengthen documentation practices and ensure accurate coding
Collaborate with leadership to refine audit tools, policies, and procedures related to the CDIS audit function
Assist in conducting focused post-discharge documentation and coding audits as requested by hospital clients system-wide
Adhere to all organizational policies, procedures, and standards, ensuring the delivery of safe and compassionate care to patients, staff, and visitors
Promote individual professional growth and development through participation in mandatory/continuing education and skills competency programs
Demonstrate commitment to delivering personalized experiences and upholding service standards that align with our organization's values
Employment Type: Full-Time
Salary: $ 80,486.00 Per Year
Job Description
Minimum Qualifications
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 Clinical Documentation Specialist (CDS) experience
Previous experience in CDIS auditing, education, and/or supervisory/management roles preferred
Strong proficiency in computer applications including MS Office (Word, Excel, Outlook) and 3M Coding and Reimbursement software; experience with Cerner EMR preferred
Excellent communication, analytical, and problem-solving skills
Exceptional organizational skills with keen attention to detail
Self-motivated with the ability to work both independently and collaboratively within a team
Flexible with excellent multitasking abilities and the capacity to prioritize tasks effectively
Principal Accountabilities
Conduct audits of case reviews and queries performed by Clinical Documentation Specialists (CDIS) to ensure quality and compliance
Track, analyze, and report audit findings to management, identifying trends and opportunities for improvement
Provide clear explanations and interpretations on missing, unclear, or non-compliant information captured by CDIS, addressing knowledge gaps as needed
Stay updated on clinical and coding guidelines, particularly in an ICD-10 coding environment, to facilitate physician documentation improvement
Develop and deliver training and education sessions for physicians and CDIS staff to strengthen documentation practices and ensure accurate coding
Collaborate with leadership to refine audit tools, policies, and procedures related to the CDIS audit function
Assist in conducting focused post-discharge documentation and coding audits as requested by hospital clients system-wide
Adhere to all organizational policies, procedures, and standards, ensuring the delivery of safe and compassionate care to patients, staff, and visitors
Promote individual professional growth and development through participation in mandatory/continuing education and skills competency programs
Demonstrate commitment to delivering personalized experiences and upholding service standards that align with our organization's values
Employment Type: Full-Time
Salary: $ 80,486.00 Per Year
Source : Get It Recruit - Healthcare