Clinical Documentation Auditor

Clinical Documentation Auditor

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How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well‑being of every person we serve. We are proud to have become a shining example of what’s possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people’s lives.

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The Clinical Documentation Integrity (CDI) Auditor evaluates the quality and accuracy of the clinical documentation in the patient record, and works with the CDI team, providers, and coders to make sure the record shows the patient’s clinical severity and level of service. The CDI auditor also looks at the performance of the CDI team and finds areas to improve. CDI auditor audits provider documentation, CDI and coding accuracy to confirm or find ways to improve proper documentation.

CDI auditor gives feedback and education to the CDI team and coders on documentation and coding best practices and helps the CDI department and organization achieve clinical and operational excellence in Clinical Documentation Improvement efforts.

• Specializes in performing CDI/Coding audits for improving financial and quality (AHRQ) metrics, collaborating with CDI Education Lead to ensure stakeholder education, assisting remotely with preparing provider education materials, and conducting reviews such as PSI, HAC, HAI, mortality according to management assignments.
• Initiates audits and prepares findings to assist CDI Education Lead in providing regular CDI education to stakeholders based on trends and industry events.
• Audits medical records to determine opportunities related to clinical documentation improvement, PSI, HACs, mortality, etc.
• Conducts real‑time audits, queries and reports, and provides feedback on process and query compliance, reviewing data and trends to identify additional opportunities.
• Performs validation and special project tasks to support the CDI Leadership, ensuring appropriate data is entered, captured, and reported in the CDI software.
• Functions as a super‑user with CDI software and all related applications, reviewing documentation remotely during admissions to identify opportunities to improve physician documentation and communicating findings.
• Submits electronic queries to clinicians and ensures documentation of complete and accurate records for coding assignments post‑discharge.
• Ensures query compliance and proper follow‑up, escalates delays promptly, and provides data to CDI Leadership.
• Reconciles records daily in the Solventum/3M 360 Encompass CDI tool and maintains weekly/monthly metrics, meeting productivity standards.
• Participates in required departmental meetings, conference calls and presentations, adhering to policies and ensuring hospital compliance with federal and state regulatory requirements.
• Maintains knowledge of coding and billing rules and regulations to support appropriate reimbursement.
• Performs other duties as assigned and complies with all Wellstar Health System policies, standards of work, and code of conduct.

• Associate’s Nursing, Bachelor’s Health Science, Accredited Program Health Science, or Doctorate in Medicine.

All certifications are required upon hire unless otherwise stated.

• Cert Clin Document Specialist within 180 days or Cert Document Improvement Practice within 180 days.
• Reg Nurse (Single State) – Preferred, RN – Multi‑state Compact – Preferred, Cert Coding Specialist – Preferred, Cert Professional Coder – Preferred, Reg Health Information Administrator – Preferred, Reg Health Information Technician – Preferred.

It is expected that all RNs are licensed, knowledgeable, and uphold the practice of nursing as outlined by the Scope of Practice and Code of Ethics standards put forth by the…