Clinical Documentation Auditor

Job Description: - Conduct regular, detailed audits of clinical documentation in medical records to ensure accuracy, completeness, and compliance with ICD-10-CM/PCS, CPT, and DRG guidelines. - Evaluate provider documentation to ensure that the medical necessity is established and coding reflects the severity of illness, risk of mortality, and overall resource utilization. - Identify documentation deficiencies and trends; provide constructive feedback and recommendations for improvement. - Collaborate with CDI specialists, coders, and physicians to clarify documentation and resolve inconsistencies. - Prepare detailed audit reports, including findings, trends, and opportunities for improvement. - Assist in developing and delivering education and training materials for providers and clinical staff regarding documentation standards and best practices - Stay current with coding guidelines, regulatory changes (CMS, Joint Commission, etc.), and industry best practices. - Participate in quality improvement initiatives and support internal and external audits as needed. Skills: Documentation, Audits, Billing Experience: 6.00-8.00 Years