Clinical Documentation Auditor

Our promise to you:

Joining UChicago Medicine AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. UChicago Medicine AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

All the benefits and perks you need for you and your family:

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance

• Paid Time Off from Day One

• 403-B Retirement Plan

• 4 Weeks 100% Paid Parental Leave

• Career Development

• Whole Person Well-being Resources

• Mental Health Resources and Support

• Pet Benefits

Schedule:

Part time

Shift:

Day (United States of America)

Address:

5101 WILLOW SPRINGS RD

City:

LA GRANGE

State:

Illinois

Postal Code:

60525

Job Description:

• Schedule: Part Time, 24 hours/week; flexible scheduling within standard business hours

• Remote role but candidate must be local to area. Must be available for in-person meetings every other month and in-person training/education as needed

Completes accurate and timely record reviews to ensure the integrity of documentation compliance. Inputs data accurately and concisely into CDI Software. Reviews concurrent and retrospective medical records for documentation compliance, including completeness and accuracy for SOI, ROM, and quality. Supports CDI documentation strategies and educates self and team members through monthly mandated education sessions and provided educational tools. Conducts quality audits, including deceased second-level reviews, focused disease process reviews, patient safety indicators, and CDI team audits. Collects, analyzes, and reports data to the CDI Leadership team. Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance. Educates patient-care team members on documentation regulations and guidelines, including quarterly and annual compliance updates from Medicare. Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients. Presents opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members. Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs. Other duties as assigned.

Knowledge, Skills, and Abilities:
• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations. [Required]
• Able to organize and present information clearly and concisely. [Required]
• Excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills. [Required]
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist. [Required]
• Dependable, self-motivated, and pleasant. [Required]
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills. [Required]
• Knowledge of pathophysiology, disease processes and treatments. [Required]
• Strong ability to organize/triage work and manage multiple priorities at once. [Required]
• Knowledge of quality guidelines. [Required]
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures. [Preferred]
• Coding background. [Preferred]

Education:
• Bachelor's [Required]
• Master's [Preferred]

Field of Study:
• of Science in Nursing and 3 years of Clinical Documentation Integrity Specialist experience OR 4 years of recent Clinical Documentation Specialist experience
• of Science in Nursing
• or higher degree in a healthcare related field

Work Experience:
• 1+ of second level review CDIS experience
• 4+ of recent clinical documentation specialist experience [Required]
• 5+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required]
• 5+ CDI experience

Licenses and Certifications:
• Certified Billing and Coding Specialist (CBCS) [Preferred]

Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/23km2677

Pay Range:

$71,588.85 - $133,150.39

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.