Clinical Documentation Quality Reviewer

Job Summary

To support the Clinical Documentation department, the full-time Clinical Documentation Integrity Quality Reviewer will conduct audits of clinical documentation, collaborate with various healthcare teams to resolve discrepancies, and provide training to enhance documentation practices, all while working remotely during weekdays.

Key responsibilities

• Conduct retrospective and concurrent audits of clinical documentation to ensure compliance with standards and prepare audit reports
• Collaborate with HIM, Coding, and Compliance teams to resolve documentation discrepancies and ensure cohesive practices
• Develop and deliver training sessions based on audit findings to enhance CDI team competency and knowledge of documentation standards

Required qualifications

• Doctor of Medicine (MD), Doctor of Osteopathy (DO), Foreign Medical Graduate (FMG), or Registered Nurse (RN)
• RHIA, RHIT, or related clinical/allied health degree
• Minimum of 5 years of inpatient clinical experience and 2+ years in clinical documentation or coding
• Experience with ICD-10-CM/PCS, DRGs, and healthcare compliance requirements
• CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner), or equivalent required