Clinical Documentation Auditor

Job Description:

• Conduct regular, detailed audits of clinical documentation in medical records to ensure accuracy, completeness, and compliance with ICD-10-CM/PCS, CPT, and DRG guidelines.
• Evaluate provider documentation to ensure that the medical necessity is established and coding reflects the severity of illness, risk of mortality, and overall resource utilization.
• Identify documentation deficiencies and trends; provide constructive feedback and recommendations for improvement.
• Collaborate with CDI specialists, coders, and physicians to clarify documentation and resolve inconsistencies.
• Prepare detailed audit reports, including findings, trends, and opportunities for improvement.
• Assist in developing and delivering education and training materials for providers and clinical staff regarding documentation standards and best practices
• Stay current with coding guidelines, regulatory changes (CMS, Joint Commission, etc.), and industry best practices.
• Participate in quality improvement initiatives and support internal and external audits as needed.