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Clinical Documentation Integrity Quality Auditor (NICU Experience Required)
JOB SUMMARY:
The Clinical Documentation Integrity (CDI) Auditor is responsible for completing quality assurance reviews of patient medical records to ensure accurate and complete documentation to reflect the patient’s severity and complexity of illness. The CDI Auditor will audit records previously reviewed by Customer CDS consultants. The chart will be reviewed for missed opportunities to capture greater specificity or clarify inconsistencies in the clinical picture of the patient. Queries posed by the Customer CDS will be reviewed from a compliance perspective, utilizing ACDIS/AHIMA Practice Brief (2022) as the standard. Adherence to Customer specific CDI processes or procedures may also be reviewed. The CDI Auditor may also review accounts not previously reviewed by Customer CDS to identify opportunities for improvement. The CDI Auditor will work within Customer systems and e4health Audit software to identify areas of risk, documentation opportunities, identifiable trends, and assist with report writing as appropriate. This position is expected to interact with the Customer appropriately and other team members.
- Review medical records as assigned for complete and accurate documentation of all relevant diagnoses and procedures
- Identify missed documentation opportunities within medical records as previously reviewed or not reviewed by Customer CDI team
- Evaluate queries from a compliance perspective to determine if there are any areas of risk, using ACDIS/AHIMA Practice Brief as the standard
- Assess adherence to Customer specific CDI processes/procedures
- Adhere to guidelines as set forth by ACDIS, AAPC, and AHIMA
- Demonstrate understanding of the business of healthcare: MS and APR DRG payer issues, audit risks, documentation opportunities, POA, quality metrics, hierarchical condition categories, and various risk adjustment methodologies
- Work closely with the Customer, co-workers, and management to meet the specific needs of each assignment in alignment with core values
- Effectively utilize computer software based on the specific Customer requirements
- Maintain strict confidentiality of all patient information in accordance with HIPAA
Requirements:
REQUIRED QUALIFICATIONS:
- Candidate must possess current ACDIS CCDS or AHIMA CDIP certification
- 3+ years of clinical documentation experience required with an acute care facility required
- 2+ years of CDI auditing experience
- Must have NICU CDI Audit experience
- Current RN license or graduate of medical school with 5+ years of acute care experience preferred; some Customers may require RN
- Thorough understanding of both MS and APR DRG methodologies and Compliant Query Practices as outlined by ACDIS/AHIMA
- Strong analytical skills to clinically evaluate the medical record
- Ability to independently use multiple computer applications for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
- Ability to communicate effectively with e4health management and Customers
- Proficiency with ICD-10-CM and ICD-10-PCS
PREFERRED QUALIFICATIONS:
- Coding credentials such as CCS is preferred
- BSN, in addition to RN license is preferred
- Experience with multiple health facilities, multiple electronic medical records, and multiple encoders strongly preferred
- Familiarity with various risk models strongly preferred
- Understand of HAC/PSI models, including exclusionary opportunity is preferred