Clinical Documentation Integrity; CDI) Auditor

## Clinical Documentation Integrity (CDI) Auditor Apply:
Fort Worth, TX:
Full time:
Posted Today:
JR-119599
*
* Location:

** Medical Center - Fort Worth
** Department:
** HIM-Clinical Documentation Improvement
** Shift:
** First Shift (United States of America)
** Standard Weekly

Hours:

** 40
*
* Summary:

** The Clinical Documentation Integrity Auditor will perform a variety of chart reviews related to documentation accuracy and specificity, coding accuracy & APR DRG assignment compliance. Analyzes and evaluates patient care documentation after coding and before billing and assigns codes as needed, ensures accuracy of Present on Admission status (POA) and DRGs to validate the documentation supports code specificity per compliance requirements.

Performs Pre-bill Audit (PBA) reviews, tracks, trends and reports audit results. Provides feedback & education regarding opportunities for documentation improvement to providers and coders. Provides expertise in ICD coding, DRG assignment, documentation guidance and education, and assists in setting goals and priorities for the coding team. Review payor coding denials for appropriate and accurate coding. Review concurrent admissions and create documentation clarification queries requesting providers to provide additional documentation within the record.

Functions as the liaison between the Coding staff, Physician Advisors and Providers. Communicates with and educates Physician Advisors and providers regarding areas of documentation improvement. Reports audit results to appropriate individuals, groups and committees on a monthly or as requested basis. Fosters relationships between all disciplines. Maintains current and thorough knowledge and understanding of clinical documentation improvement, Epic systems, coding schemes, APR-DRG groupers, Cooks policies, procedures, regulatory requirements and guidelines for documentation, coding and billing/reimbursement.

Education:

* Must have an Associates degree in Business or Clinical field (i.e. Nursing, Health Information Management, etc.). Masters Degree in health-related field desirable
* Must have a minimum of three (3) years current & continuous acute care hospital inpatient coding required for Coding Professionals.
* 1-2 years APR/DRG coding and clinical validation auditing experience in a pediatric setting highly desired. ICD-10-CM training highly preferred.
* 2 years acute nursing experience required for RNs. Pediatric ER or ICU nursing experience for RNs preferred.
* Certified Clinical Documentation Specialist (CCDS) credential and/or Certified Documentation Improvement Practitioner (CDIP) credential is preferred along with knowledge of ICD-10, and APR-DRGs. Will be required to obtain on or before the third-year hire date.
* Demonstrates superior coding expertise and critical thinking skills with the ability to solve problems appropriately using knowledge and current policies/procedures, guidelines and regulations.
* Technically competent and fluent knowledge in navigation of electronic medical record applications, coding decision support tools, including encoders, abstracting & billing systems, electronic medical records (used as coding source documents) and other associated computer applications required.
* Proficiency in computer assisted coding/CDI tools, automated coding work flow process and management of coded data integrity highly desired. Experience using Microsoft Office applications (excel, word, outlook, power point) required.
* Ability to remain focused, work well independently and productively with minimal guidance and without direct supervision.
* Must have sharp analytical and critical thinking skills, must be highly detail oriented, have strong organizational skills, writing, interpersonal and…