Newport News, Virginia

The Clinical Documentation Improvement (CDI) Auditor will facilitate improvement system-wide in the overall quality, completeness, and accuracy of the medical record documentation through extensive audit investigation, education and data analysis. Responsible for identification of patterns, trends, and opportunities for CDI staff to improve accuracy and outcomes. Provides education to CDI team members and physicians, if needed. Assists with denial management as it relates to documentation.

What you will do

• Performs quality audits on CDI team members and provides education and feedback. Ensures coding compliance; applies all coding guidelines as defined in the Coding Clinic and leading authorities. Complies with standardized coding standards, conventions and regulations, corporate compliance standards and reimbursement policies.
• Identifies and provides training to ensure quality and productivity standards are met. Provides education on compliant query process. Coordinates huddles as needed.
• Maintains a working knowledge of new coding and DRG guidelines and regulations. Implements policies and procedures around changes and works with manager to interpret and apply the changes.
• Prepares audit reports for CDI leadership.
• Develops and maintains compliant physician query templates.
• Serves as a clinical coding liaison. Analyzes and evaluates documentation issues with consultation from medical staff, clinical staff, clinical documentation team and other departments as needed.
• Develops, and delivers CDI education for physicians, coders, and CDI team members. Coaches and develops team members to achieve team goals that support business strategies and objectives.
• Assists patient financial services and coding team members with questions around CDI processes, procedures, coding and queries.
• Assists leadership in the coordination of iCare initiatives related to the hospital CDI department.
• Collaborates with Quality, CDI team, Coding Team, leadership, Physician ad visor and is a SME/resource on CDI for RHS
• Assists with preparation and presentation of clinical documentation monitoring/trending reports for review
• Performs research and analysis of data obtained
• Documents findings related to Compliance Reviews
• Adheres to established productivity standards.
• Communication with CDI and CDI Director of case and resolution

Qualifications

Education

• Associates Degree, Nursing (Required)
• Bachelors Degree, Nursing or healthcare related (Preferred)

Experience

• 3-4 years Nursing experience, preferred patient care, critical care, utilization management, quality, or patient navigator. (Required)
• 3-4 years CDI experience (Required)
• 1 year auditing experience (Required)

Skills and Abilities

• Knowledgeable in Microsoft Office, encoder and use of EHR
• Ability to provide CDI and/or coding education to providers, CDI and Coders
• Strong verbal and written communication skills.
• Excellent attention to detail
• Ability to apply audit standards.
• Intermediate proficiency with Excel, PowerPoint, Word
• Excellent interpersonal and presentation skills.
• Strong time management, attention to detail, and follow through.
• Knowledge of the human disease process, anatomy & physiology and medical terminology.
• Possesses an excellent understanding of coding practices, official coding guidelines and federal regulations.
• Ability to adapt to changes in the work environment.

Licenses and Certifications

• Registered Nurse (RN) - State Department of Health Professions (Required) and
• Certified Clinical Document Specialist (CD) - Association of Clinical Documentation Integrity Specialists (ACDIS) (Required) or
• Certified Documentation Integrity Practitioner (CDIP) - The American Health Information Management Association (AHIMA)
• Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) (Preferred) or
• Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA) or
• Registered Health Information Technician (RHIT) - The American Health Information Management Association (AHIMA)

To learn more about being a team member with Riverside Health System visit us at https://www.riversideonline.com/careers.