Clinical Documentation Audit Specialist

Job Details

Clinical Documentation Audit Specialist

Job Description

Under the direction of the Senior Director of Clinical Documentation Improvement (CDI) and CDI Manager, the CDI Audit Specialist provides expert level CDI reviews of targeted medical records throughout the enterprise to assist management in ensuring accurate quality data reporting and providing educational feedback to CDI managers. This position will support organizational goals by identifying opportunities to partner with providers to more accurately capture patients' clinical pictures to reflect Jefferson's superior patient care, participating in enterprise-wide performance improvement efforts, and demonstrating a commitment to teamwork and cooperation. 

1. Interacts with co-workers, visitors, & other staff consistent with the values of Jefferson.

2. Accurately reviews designated medical records for completeness in documentation of diagnostic and procedural information in compliance with Center for Medicare Services (CMS), Department of Health regulatory, and financial requirements. Provides an expert level review of targeted medical records to ensure accurate data capture of patient diagnoses and procedures. 

3. Performs second level reviews on designated records (i.e. mortality, Patient Safety Indicator reviews, sepsis, etc.) to ensure accurate quality reporting and serves as department liaison for quality related meetings.

4. Prepares well written and compliant queries to communicate with physicians and other providers regarding clarifying conflicting, missing, or incomplete documentation in the medical record. 

5. Supports revenue cycle initiatives in managing the load of cases that are discharged but not final billed by supporting timely CDI query follow-up in accordance with query escalation process. 

6. Coordinates with management to utilize expert level CDI skills to conduct quarterly quality record review audits of CDI specialists across the enterprise. 

7. Assists with enterprise-wide documentation improvement quality initiatives. Evaluates opportunities for CDI education and/or CDI workflow and process improvements. 

8. Participates on hospital committees to conduct record review studies, as necessary, to facilitate improvement in clinical documentation processes to ensure overall quality, completeness, and compliance. 

Required Knowledge, Skills, and Abilities (Proficiencies):

Prior exposure to quality record reviews (i.e. Patient safety indicators, mortality) preferred.  Strong working knowledge and experience in clinical record reviews, 3M encoder coding systems, Diagnostic Related Group (DRG) system, and Epic EHR system required. Expert level working knowledge of ICD-10 diagnosis and procedural coding conventions and severity of illness/risk of mortality required. Excellent interpersonal and communication skills (both written and verbal) with previous experience working collaboratively within teams required.  Ability to work remotely and manage participation in multiple committees. Prior data analytic skills and understanding case mix index and DRG/all patient refined (APR) diagnosis related group systems. Strong working knowledge of Microsoft Office; Outlook, Word, Excel, PowerPoint. 

Required Experience, Education, Certification:

Education: Bachelor of Science in Nursing, Medical Graduate degree, or Bachelor's Degree in Health Information Management or other related field or 4 years related clinical experience in lieu of bachelor's degree. 

Experience: Minimum two years experience in clinical documentation improvement. Minimum of three years hands-on clinical experience either obtained through clinical experience in nursing (i.e. RN, BSN), medical school, respiratory therapy, physician assistant, or residency or 5 years of inpatient acute care medical coding experience in lieu of clinical experience. 

Certification: Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certifications required.

BSN, PA or medical graduate degree preferred. Experience with hospital acquired conditions, patient safety indicators, and risk adjustment methodology (specifically Vizient, Elixhauser, or Hierarchical Condition Category) preferred. Prior presentation and educational training skills preferred. Successful completion of Vizient Risk Adjustment Training.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Abington Memorial Hospital

Primary Location Address

1200 Old York Road, Abington, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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