Clinical Documentation Audit Specialist Job Reading area,Pennsylvania USA,Healthcare

Job Details

Clinical Documentation Audit Specialist

Job Description

Under the direction of the Senior Director of Clinical Documentation Improvement (CDI) and CDI Manager, the CDI Audit Specialist provides expert level CDI reviews of targeted medical records throughout the enterprise to assist management in ensuring accurate quality data reporting and providing educational feedback to CDI managers. This position will support organizational goals by identifying opportunities to partner with providers to more accurately capture patients’ clinical pictures to reflect Jefferson’s superior patient care, participating in enterprise-wide performance improvement efforts, and demonstrating a commitment to teamwork and cooperation.

Interacts with co-workers, visitors, & other staff consistent with the values of Jefferson.

Accurately reviews designated medical records for completeness in documentation of diagnostic and procedural information in compliance with Center for Medicare Services (CMS), Department of Health regulatory, and financial requirements. Provides an expert level review of targeted medical records to ensure accurate data capture of patient diagnoses and procedures.

Performs second level reviews on designated records (i.e. mortality, Patient Safety Indicator reviews, sepsis, etc.) to ensure accurate quality reporting and serves as department liaison for quality related meetings.

Prepares well written and compliant queries to communicate with physicians and other providers regarding clarifying conflicting, missing, or incomplete documentation in the medical record.

Supports revenue cycle initiatives in managing the load of cases that are discharged but not final billed by supporting timely CDI query follow-up in accordance with query escalation process.

Coordinates with management to utilize expert level CDI skills to conduct quarterly quality record review audits of CDI specialists across the enterprise.

Assists with enterprise-wide documentation improvement quality initiatives. Evaluates opportunities for CDI education and/or CDI workflow and process improvements.

Participates on hospital committees to conduct record review studies, as necessary, to facilitate improvement in clinical documentation processes to ensure overall quality, completeness, and compliance.

Required Knowledge, Skills, and Abilities (Proficiencies):

Prior exposure to quality record reviews (i.e. Patient safety indicators, mortality) preferred. Strong working knowledge and experience in clinical record reviews, 3M encoder coding systems, Diagnostic Related Group (DRG) system, and Epic EHR system required. Expert level working knowledge of ICD-10 diagnosis and procedural coding conventions and severity of illness/risk of mortality required. Excellent interpersonal and communication skills (both written and verbal) with previous experience working collaboratively within teams required.

Ability to work remotely and manage participation in multiple committees. Prior data analytic skills and understanding case mix index and DRG/all patient refined (APR) diagnosis related group systems. Strong working knowledge of Microsoft Office;
Outlook, Word, Excel, PowerPoint.

Required Experience, Education, Certification:

Education:

Bachelor of Science in Nursing, Medical Graduate degree, or Bachelor’s Degree in Health Information Management or other related field or 4 years related clinical experience in lieu of bachelor’s degree.

Experience:

Minimum two years experience in clinical documentation improvement. Minimum of three years hands-on clinical experience either obtained through clinical experience in nursing (i.e. RN, BSN), medical school, respiratory therapy, physician assistant, or residency or 5 years of inpatient acute care…