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Clinical Documentation Specialist Auditor – HIM Coding & CDI Quality

UNC Health
Published
May 10, 2024
Location
Chapel Hill, NC
Job Type
Work Setting
Remote / Home-based

Description

This positon trains and audits Inpatient and Outpatient Clinical Documentation Specialists (CDS) across all HCS entities that are owned or managed that have opted into shared services. This position reports to the HCS Supervisor Coding and CDI Quality and Training. This position may travel from entity to entity across the state to train and shadow round with Clinical Documentation Specialists. The CDS auditor provides elbow to elbow support during training and education as well as through webex. This position may travel to clinics and work with physicians and CDS on documentation education and issues for optimizing HCCs.

Responsibilities

  • Audits CDS to assure a minimum of 95% accuracy and recommends education and training related to results.
  • Monitor and provide feedback to new-hire CDS, as they progress through and complete the CDS training modules.
  • Provides ongoing documentation and coding education to CDI Physician Advisers and CDS staff.
  • Provides input to the CDS's performance evaluation completed and conducted by the Supervisor.
  • Participates in the hiring and selection of new CDS with the hiring manager as requested.
  • Analyzes and audits medical records concurrently to ensure that the clinical information within the medical record is accurate, complete, and compliant.
  • Educates CDS, physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories and complexity of care rendered to all patients. Educates on proper creation of provider compliant queries.
  • Ensures compliance with third party and State and Federal regulations.
  • Audits CDS medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality.
  • Assures accurate assignment of Working MS-DRG, ICD-10-CM/PCS codes and CPT codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations.
  • Identifies cases for CDI Physician Advisor intervention and coordinates the CDI Physician Advisor scheduling, reviews and educational opportunities with residents, faculty, Advanced Practice Professionals (APP).
  • Collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits and ROI.
  • Assists with overseeing the quarterly CDI Physician Advisor meetings to discuss the status of the program and generates the dashboard reports for review and discussion.
  • Conducts with the assistance/input of the appropriate CDS, educational sessions for physicians, CDI Physician Advisors, and coding staff as well as the CDS staff.

Education 

  • Associate's degree in Health Information Management, Nursing or related field.
  • Successful completion of the Clinical Documentation Specialist Proficiency Test.

Licensure/Certification Requirements

  • Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license with applicable credential.

Professional Experience

  • Three (3) years of CDS experience

Knowledge/Skills/and Abilities Requirements

  •  Strong knowledge of ICD-10-CM, ICD-10-PCS, and CPT coding, MS DRG, hierarchical condition categories (HCC), and CDI documentation processes.
  • Ability to interpret federal and state regulations as they relate to coding and compliance.
  • Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills.
  • Strong critical thinking and sound judgement in decision making.
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