Essential Job Functions Initial Audit and Education For assigned coding staff, conduct initial quality audits as they go through onboarding process for new project/client assignment, and provide education to staff based on initial quality audit findings. Review medical records for accuracy of coding and data quality. Elements included in reviews may include: Auditing: Reviewing medical records, including clinical notes, lab results, and other diagnostic information, to ensure documentation accurately reflects diagnoses, severity of illness, and risk of mortality. Compliance: Ensuring documentation complies with regulatory requirements, coding guidelines, and payer rules. Identifying Gaps: Identifying missed documentation opportunities, inconsistencies, and areas where documentation can be more specific or clarified. Query Review: Evaluating the appropriateness of queries issued to physicians, ensuring they are supported by clinical evidence and aligned with coding guidelines. Data Analysis: Analyzing data related to CDI performance, identifying trends, and reporting findings to leadership. Education and Training: Providing education and training to CDI staff, physicians, and other healthcare professionals on documentation best practices, coding guidelines, and regulatory requirements. Skills and Qualifications Clinical Knowledge: Strong understanding of disease processes, clinical conditions, and medical terminology. Coding Knowledge: Familiarity with ICD-10-CM/PCS, CPT, and other relevant coding systems. CDI Experience: Experience in clinical documentation integrity, including chart review and query writing. Analytical Skills: Ability to analyze data, identify trends, and make recommendations for improvement. Communication Skills: Excellent written and verbal communication skills to effectively communicate with various healthcare professionals. All diagnosis and procedure assigned ICD-10-CM and ICD-10-PCS codes. Appropriateness of queries created. Outpatient Cases (ER, SDS, Ancillary) All diagnosis and procedure assigned ICD-10-CM and ICD-10-PCS codes. All CPT assigned codes. APC assignment. Qualifications for Internal Candidates Employee must be fluent in auditing facility inpatient, Outpatient is a plus. Will be trained in DRG appeal writing. Must be experienced in Word and Excel. CDI credential is a plus. Qualifications Must have CDI (Clinical Documentation integrity); CDIP(AHIIMA), CCDS (ACDIS) or CDEI (AAPC) #J-18808-Ljbffr
Auditor/Educator In/Outpatient • Boca Raton, FL, United States
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