Clinical Documentation Specialist, Audit Coordinator
Job Description:
- Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs
- Utilizes advanced coding and/or clinical expertise to improve clinical documentation
- Responsible for reviewing and/or auditing medical record clinical documentation to support medical necessity and accurate coding
- Audits HM CDSs for query compliance and missed documentation opportunities
- Trains end users in the use of CDI system software and workflow
- Conducts clinical documentation chart reviews and queries providers as appropriate
Requirements:
- Current Registered Nurse License or Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS)
- Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred
- Experience in Clinical Documentation Integrity
- Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills
- Strong critical thinking skills and ability to integrate knowledge
- Prioritization and organizational skills required
- Ability to educate all members of the healthcare team related to clinical documentation
- Experience with databases, spreadsheet software and presentation software preferred
Benefits:
- Health insurance
- Professional development opportunities
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