Clinical Documentation Integrity (CDI) - Audit & Education
Details
- Department: Administration
- Schedule: Full Time, Days
- Location: Remote
- Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
- Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).
- Identify trends, variances, and opportunities for improvement in CDI team performance.
- Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis.
- Collaborate with coding and compliance teams to align audit criteria and resolve discrepancies.
- Develop and deliver comprehensive CDI education programs, including onboarding, continuing education, and skills refreshers for CDSs.
- Provide one-on-one coaching for new or developing team members, based on audit findings or performance trends.
- Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.
- Offer targeted documentation education to providers through presentations, individual feedback, and query response coaching.
- Support rollout of new coding or documentation guidance, EHR tools, and CDI initiatives across the enterprise.
- Participate in national or regional CDI education forums to maintain subject matter expertise and incorporate best practices.
- Provide just-in-time feedback to providers and support educational initiatives based on current trends or gaps.
- Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
- High School diploma equivalency with 2 years of cumulative experience OR Associate's
- Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.
- Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
- Exceptional written and verbal communication skills.
- Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).
- Analytical, detail-oriented, and solution-focused, with excellent organizational and time management skills.