Clinical Documentation Integrity Auditor

The Clinical Documentation Improvement (CDI) Auditor is responsible for evaluating the quality, accuracy, completeness, and compliance of clinical documentation and CDI review processes. This role performs audits of inpatient medical records, CDI queries, and documentation practices to ensure accurate code assignment, compliant reimbursement, quality reporting, and regulatory compliance.

The CDI Auditor partners with CDI Specialists, Coding professionals, physicians, and operational leadership to identify documentation improvement opportunities, validate CDI program effectiveness, educate staff, and support continuous quality improvement initiatives.

If you’re looking for a career where your skills are valued and your work makes a difference, you’ll find your place at Ensource.

Essential Responsibilities

• Perform audits of CDI reviews, medical records, and provider queries to evaluate the accuracy, completeness, and consistency of CDI specialists' work.

• Assess CDI specialists' documentation review practices, query opportunities, and compliance with organizational policies and industry standards.

• Provide individualized coaching, mentoring, and education to CDI Specialists based on audit findings to improve clinical judgment, documentation review techniques, query writing, and overall performance.

• Serve as the CDI department's subject matter expert by educating staff on MS-DRGs, APR-DRGs, ICD-10-CM/PCS, Severity of Illness (SOI), Risk of Mortality (ROM), clinical validation, and compliant physician query practices.

• Evaluate provider queries for clinical accuracy, compliance, and effectiveness, ensuring adherence to AHIMA, ACDIS, and organizational guidelines.

• Validate accurate capture of diagnoses, procedures, CCs, MCCs, and other documentation impacting reimbursement, quality measures, and regulatory reporting.

• Maintain current knowledge of CMS regulations, coding guidelines, CDI best practices, and emerging industry trends to ensure the CDI program remains compliant and effective.

Qualifications

• Minimum of five (5) years of Clinical Documentation Improvement (CDI) experience in a large acute care hospital setting.
• Minimum of three (3) years conducting CDI quality reviews, audits, or performance improvement initiatives.
• Strong knowledge of:
  • ICD-10-CM/PCS
  • MS-DRG and APR-DRG methodologies
  • Severity of Illness (SOI) and Risk of Mortality (ROM)
  • Compliant Query Writing
  • Hospital-Acquired Conditions (HACs)
  • Clinical validation principles
  • CMS regulations
  • Documentation compliance standards
• Experience reviewing concurrent and retrospective CDI cases.
• Strong analytical, critical thinking, and problem-solving skills.
• Excellent written and verbal communication skills.
• Ability to educate CDI specialists, coders, and operational leadership.
• Proficiency with Electronic Health Records (EHRs), CDI software, Microsoft Excel, and reporting tools.

Candidates should possess one or more of the following certifications:

• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Practitioner (CDIP)
• Certified Coding Specialist (CCS)
• Certified Professional Coder (CPC)
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)

Why work with us?

THERE ARE MANY BENEFITS TO WORKING AT Ensource, INCLUDING:

• Full-time, Part-time & PRN positions

• Health Insurance (medical, dental, vision), Flexible Spending Account, & Aflac Group Products

• Volunteer ReachOut Program: 40 Hours of Paid Time to Volunteer

• 401(k)/Roth with Company Match

• Healthy Work-Life Balance

• Collaborative Work Environment

• Flexible Work Schedule

• PTO for Full & Part-Time Employees

• Employee Incentive Reward Program

• Annual Stipend for Professional Certifications and Memberships (for Medical Coding Employees)

Travel: 0% No Travel Anticipated

Pay Range: $48-$58 Hourly