Clinical Documentation Specialist, Audit Coordinator

Responsibilities

• Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool.
• Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
• Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients.
• Audits HM CDSs for query compliance, workflow and missed documentation opportunities.
• Trains end users in the use of CDI system software, standards, and workflow.
• Demonstrates understanding of and facilitates appropriate clinical documentation to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record.
• Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs.
• Reviews may be conducted on site or remotely.
• Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations.
• Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment.
• Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities.
• Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
• Demonstrates ability to quickly learn and master the various CDI technology applications, systems and workflows in place across the enterprise.
• Provides expertise in problem‑solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
• Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
• May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested.
• Performs other duties as assigned by leadership.

Qualifications

• Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), 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.
• Must be comfortable operating independently in a collaborative, shared leadership environment.
• Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
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