Clinical Documentation Auditor

The role of the Clinical Documentation Auditor (remote) involves reviewing medical record documentation and coding abstracts to ensure all medical record documentation supports services rendered and reported on healthcare claims, as well as and meeting all regulatory and internal policy requirements.

Community Health Systems is one of the nation’s leading operators of general acute care hospitals. The organization’s affiliates own, operate or lease 84 hospitals in 16 states with approximately 13,000 licensed beds. Affiliated hospitals are dedicated to providing quality healthcare for local residents and contribute to the economic development of their communities. Based on the unique needs of each community served, these hospitals offer a wide range of diagnostic, medical and surgical services in inpatient and outpatient settings.

The role of the Clinical Documentation Auditor (remote) involves reviewing medical record documentation and coding abstracts to ensure all medical record documentation supports services rendered and reported on healthcare claims, as well as and meeting all regulatory and internal policy requirements.

SUMMARY:

 The Clinical Documentation Auditor- CDA (remote) will work under the supervision of the Director, Corporate Compliance Facility Coding & Documentation Audit.  The CDA utilizes clinical knowledge and technical specifications to review documentation and files from medical records that align with CMS and other governing agencies.  The CDA will be responsible for reviewing a wide range of diagnostic, medical and surgical services in inpatient and outpatient settings at CHSPSC, LLC’s affiliated facilities. The position will work closely with Corporate Compliance, Health Information and Informatics Management, and Clinical Documentation Improvement departments, as well as other relevant stakeholders. 

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•  Perform detailed inpatient and outpatient medical record reviews
•  Review coding abstracts, UB-04s, 1500s, and Remittance Advices
•  Validate the presence/absence of documentation that supports appropriate coding, medical necessity, utilization, reimbursement, and patient care quality data
•  Analyze and summarize technical documents (such as CMS publications and coding guidelines) and internal/external data from a variety of sources
•  Develop and present basic and intermediate education for CHS personnel using a variety of methods – informal, webinar, newsletter articles, etc.
•  Collaborate with relevant stakeholders to improve physician/clinician understanding of documentation requirements
•  Keep abreast of regulatory changes related to coding, documentation and reimbursement systems
•  Maintain broad knowledge of clinical aspects of diagnoses and treatments/procedures
•  Track and report audit activities and results
•  Participate in team meetings, conference calls, and educational activities with relevant stakeholders
•  Travel occasionally for meetings or training sessions
•  Perform other duties as assigned by Corporate Compliance Department leadership

QUALIFICATIONS: 

 The candidate must be able to perform the essential duties and responsibilities outlined above.  The requirements listed below are representative of the knowledge, skills, and/or abilities required for success in this position.

 CERTIFICATES, LICENSES, REGISTRATIONS:

•   RN with current licensure is required
•  One or more of the following certifications are required: RHIT, RHIA, CCS, COH, CIC, CPC, CDIP or CCDS
•  CHC certification is preferred, but not required
•  Other comparable certifications in coding, auditing, healthcare compliance, or clinical documentation may be considered

EDUCATION:

 Degree in nursing from an accredited school of nursing, college or university (ASN, AAN, AND, BSN, RN Diploma, MSN or comparable degree)

EXPERIENCE:

•  At least 5 years of acute care hospital nursing experience (e.g., medical/surgical unit, emergency department or ICU/Critical Care) is required
•  At least 2 years of experience in health care compliance, clinical documentation improvement, health information management, case management, or utilization/medical necessity review is required

KNOWLEDGE/SKILLS/ABILITIES: 

• A working knowledge of ICD-10-CM/PCS coding and DRGs is required
•  A working knowledge of CPT-4/HCPCS coding is preferred
•  Comprehensive knowledge of medical terminology, disease processes, and pharmacology is required
•  Strong written and verbal English communication skills are required
•  Proficiency with basic office software such as e-mail, word processing, spreadsheet, and electronic medical record systems (e.g., Cerner, McKesson, Epic, etc.) is required
•  Proficiency with PowerPoint or similar software is preferred
•  Proficiency with encoding software (e.g. 3M, TruCode, etc.) is preferred
•  Ability to communicate effectively with all levels of staff in a variety of healthcare/business settings is required

REASONING ABILITY:

The candidate must possess the ability to define problems, collect data, establish facts, and draw conclusions.  Must be able to think logically and critically.

PHYSICAL DEMANDS:

 Primarily sedentary work seated at a computer workstation. Visual acuity to read from computer screens and written publications.  Auditory acuity to hear normal conversation via telephone or face-to-face.  Dexterity for performing data entry and using computer mouse. Ability to travel occasionally by airline or car.