Clinical Documentation Specialist Audit and Education

• Location: Remote
• Department: Clinical Documentation Integrity
• Schedule:  Full-Time | Days | Monday-Friday

Responsibilities

• Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.
• Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
• Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis.
• Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).  Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
• Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.

Qualifications

Licensure / Certification / Registration:

Required Credential(s):

• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.

Education:

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Additional Preferences:

• Must have a Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)
• Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles.
• Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance.
• Proven ability to develop engaging education content tailored to diverse audiences (clinical, coding, administrative).
• Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance).