Senior Clinical Documentation Specialist Auditor - Clinical Doc Integrity - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

The Senior Clinical Documentation Specialist - Auditor (CDS) performs review of inpatient medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service and hospital quality metrics. Demonstrates proficiency on ICD10-CM & PCS and respective coding guidelines & regulations for coding and reporting. Matter expert of key CDI hospital quality metrics (PSI, HACs, Vizient and Elixhauser Comorbidities, etc) and Inpatient Prospective Payment System (IPPS) documentation requirements for proper APR & MS DRGs assignment. The Senior CDS - Auditor functions at a higher level by leading and supporting the CDI team; and by active participation in physician/clinical staff engagement and education. Monitors internal key indicator metrics associated with CDI as it related to the revenue cycle and quality outcomes. Strategically audits cases in regard to Denial Prevention, Quality comorbidities, Risk Adjustment related data audits, and Quality Assurance audits. Assists CDS in account reconciliation to ensure completeness of coding and documentation accuracy. Assists with denial management as it relates to documentation. Fosters teamwork & utilizes strong team building measures. Acts as consultant and educator to providers, CDI, and coding staff relative to clinical documentation and coding. Works with different specialties to ensure they are kept aware of changes.

Essential Duties:

• Directs and educates Physicians/Residents and clinical staff on CDI process/goals, and work in a collegial manner with physicians, staff and consultants.
• Supports and helps with the day-to-day operations of the team and help with the training of new employees or provides assistance when other team members need it.
• Involved in the clinical denial/appeal process for DRG challenges and clinical validations via Clinical Validation Audits/Denial Prevention, reviewing technical payor denials and determines if an appeal is justified and author appeals.
• Performs various audits, as assigned, for denial prevention, multiple quality comorbidities, risk adjustment related data audits, and quality assurance audits. Improves documentation through compliant physician query generation and provides education to providers and CDS.
• Achieves a physician response rate of 100% through CDI education of physicians, identifying non-responders and intervening as necessary. Follows the query escalation process when no response.
• Identifies opportunities to improve documentation through physician query generation. Practice the mnemonic 'MEAT' (Monitored, Evaluated, Assessed or Treated) for building compliant and non-leading CDI queries. Applies evidence-based clinical criteria for clinical validation of diagnoses
• Utilizes the CDI software properly for tracking of CDI metrics and to assure compliance: documentation of pertinent clinical findings, compliant/non-leading queries, completion of all the required fields for data integrity and professional communication with coders and other staff members
• Conducts retrospective reviews for mortality, quality metrics, payment denials or other reasons when necessary
• Auditor acts as a subject matter expert and resource for the Clinical Documentation Specialists (CDS), coders, and other departments as needed.
• May assume the role of CDS as demands for services requires, entailing the following: Conducts new inpatient admissions reviews and proper working DRG assignment within 2 working days; Conducts follow up reviews and respective working DRG updates at least every 2 working days
• Support and collaborate with Clinical Documentation Improvement Manager - Educator and Auditor, CDS Manager and CDS Director with planning, development and execution of audits, root cause analysis, solutions, and education, as needed.
• Assists Manager with accomplishment of department goals with other duties as assigned.

Required Qualifications:

• Req Bachelor's degree
• Req Graduate of an accredited school of registered nursing OR foreign medical graduate.

• Req 3 years Clinical documentation improvement experience
• Req 3 years Clinical experience in an acute care setting

Preferred Qualifications:

• Pref Certified Coding Specialist - CCS (AHIMA)

Required Licenses/Certifications:

• Req Valid California Registered Nurse license or foreign medical graduate
• Req Certified Clinical Documentation Specialist (CCDS) Certified Clinical Documentation Specialist (CCDS from ACDIS) or Certified Documentation Improvement Practitioner (CDIP from AHIMA)
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire, and maintained by renewal before expiration date.