Clinical Documentation Audit Specialist

Prior exposure to quality record reviews (i.e.

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.

Prior data analytic skills and understanding case mix index and DRG/all patient refined (APR) diagnosis related group systems.

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.

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.

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.