Clinical Documentation Auditor, Educator
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Job Description
Memorial Hermann CDI Auditor/Educator auditing clinical documentation and coding across acute-care facilities. Educating physicians and CDIS staff while improving record quality, severity capture, and compliance.
Responsibilities:
- Facilitate system-wide improvement in the quality, completeness, and accuracy of medical record documentation through audit investigation, education, and data analysis
- Identify patterns, trends, and opportunities for the CDI team across all acute care facilities
- Assist with large retrospective audits requested by hospital clients system-wide
- Educate physicians as needed
- Audit Clinical Documentation Specialist case reviews and queries for quality and compliance using audit tools
- Track, trend, and report audit findings for individual CDIS staff, hospital regions, and system-wide management
- Identify knowledge gaps and explain missing, unclear, conflicting, or non-compliant CDIS information
- Research and stay current on clinical and coding guidelines, including quarterly Coding Clinics, in an ICD-10 coding environment
- Support the quality, timeliness, and completeness of health records, provider communication, and quality outcomes
- Develop presentation materials and provide training to physicians and CDIS staff on documentation practices and accurate coding reflecting severity of illness and risk of mortality
- Conduct clinical quality audits using audit tools
- Develop and update CDIS audit policies and procedures and refine audit tools with leadership
- Collaborate with leadership on focused post-discharge documentation and coding audits requested by hospital clients
- Adhere to Memorial Hermann policies, procedures, standards, budget, time management, productivity, and service-quality requirements
- Support department goals and serve as a preceptor, mentor, and resource to less experienced staff
- Model Memorial Hermann service standards and provide safe, caring, personalized, and efficient experiences
- Perform other duties as assigned
Requirements:
- Bachelor's of Nursing required
- Master's Degree in Nursing or Management preferred
- Current State of Texas license or temporary/compact license to practice professional nursing
- One of the following certifications required: CCDS from the Association of Clinical Documentation Improvement Specialists; CDIP from AHIMA; or CCS from AHIMA
- Three years of Clinical Documentation Integrity (CDI) experience required
- Approved AHIMA ICD-10-CM/PCS Trainer preferred
- Previous CDIS auditing and education experience and/or CDIS supervisory/management background preferred
- Strong computer proficiency, including MS Office (Word, Excel, and Outlook) and 3M Coding and Reimbursement software
- Experience with Epic EMR preferred
- Excellent communication, analytical, and problem-solving skills
- Strong organizational skills and attention to detail
- Strong risk assessment, impact analysis, and problem-solving skills
- Highly self-motivated, able to work as a team player, and able to take direction
- Flexibility to multitask and prioritize daily workload, including concurrent chart reviews as needed
- MDs or doctors cannot be considered for this position
- Remote workers cannot be hired in Arizona, California, Connecticut, Maryland, Massachusetts, Missouri, New Jersey, New York, Utah, Ohio, Pennsylvania, Washington, Alabama, Mississippi, Illinois, Oregon, Arkansas, or Iowa
Benefits:
- Mandatory/continuing education and skills competency support
- Professional growth and development opportunities
- Preceptor, mentor and resource opportunities
- Compassionate and personalized experiences for employees
- Safe, caring, personalized and efficient work environment
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