Note: The job is a remote job and is open to candidates in USA. UNC Health is an inclusive organization dedicated to improving the health and well-being of the communities it serves. The Clinical Documentation Specialist Auditor is responsible for training and auditing Clinical Documentation Specialists across various entities, ensuring compliance and accuracy in medical records, and providing ongoing education to staff.

Responsibilities

• Audits CDS to assure a minimum of 95% accuracy and recommends education and training related to results
• Monitor and provide feedback to new-hire CDS, as they progress through and complete the CDS training modules
• Provides ongoing documentation and coding education to CDI Physician Advisers and CDS staff
• Provides input to the CDS's performance evaluation completed and conducted by the Supervisor
• Participates in the hiring and selection of new CDS with the hiring manager as requested
• Analyzes and audits medical records concurrently to ensure that the clinical information within the medical record is accurate, complete, and compliant
• Educates CDS, physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories and complexity of care rendered to all patients. Educates on proper creation of provider compliant queries
• Ensures compliance with third party and State and Federal regulations
• Audits CDS medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality. Assures accurate assignment of Working MS-DRG, ICD-10-CM/PCS codes and CPT codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations
• Identifies cases for CDI Physician Advisor intervention and coordinates the CDI Physician Advisor scheduling, reviews and educational opportunities with residents, faculty, Advanced Practice Professionals (APP)
• Collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits and ROI
• Assists with overseeing the quarterly CDI Physician Advisor meetings to discuss the status of the program and generates the dashboard reports for review and discussion
• Conducts with the assistance/input of the appropriate CDS, educational sessions for physicians, CDI Physician Advisors, and coding staff as well as the CDS staff

Skills

• Associate's degree in Health Information Management, Nursing or related field
• Successful completion of the Clinical Documentation Specialist Proficiency Test
• Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license with applicable credential
• Three (3) years of CDS experience
• Strong knowledge of ICD-10-CM, ICD-10-PCS, and CPT coding, MS DRG, hierarchical condition categories (HCC), and CDI documentation processes
• Ability to interpret federal and state regulations as they relate to coding and compliance
• Must possess strong communication skills, both written and verbal
• Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills
• Strong critical thinking and sound judgement in decision making

Company Overview

• Our mission is to improve the health and well-being of North Carolinians and others whom we serve. It was founded in 1952, and is headquartered in Chapel Hill, North Carolina, USA, with a workforce of 10001+ employees. Its website is https://www.unchealth.org.

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