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Clinical Documentation Auditor
Wellstar Health System. Perform CDI and coding audits to improve financial and AHRQ quality metrics .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity and coding compliance, with a strong focus on improving documentation quality and patient outcomes. Proficient in data analysis, education, and collaboration with healthcare providers to enhance clinical documentation practices.
Highest-signal resume keywords
Clinical Documentation Specialist CertificationCDI/Coding Chart Review ExperienceExpert Knowledge of Clinical Documentation IntegrityProficiency with CDI Technology ToolsStrong Understanding of Disease Processes
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical Documentation ImprovementCoding Compliance AuditingData AnalysisDocumentation Quality ImprovementMedical Record ReviewElectronic Query SubmissionHealthcare Regulations ComplianceCoding Clinic Guidelines FamiliarityProductivity Metrics MaintenanceReal-Time Audits
Soft Skills
Strong Communication SkillsCritical ThinkingTime ManagementTraining and Peer DevelopmentCollaboration
Tools & Technologies
Solventum/3M 360 EncompassEpicMicrosoft WordMicrosoft ExcelMicrosoft PowerPoint
Certifications & Qualifications
Clinical Documentation Specialist CertificationClinical Documentation Improvement Practitioner CertificationCCSCPCRHIARHIT
Industry Keywords
Acute Care SettingHealthcare ExperienceInpatient Case ManagementUtilization ReviewFederal and State Regulatory RequirementsDRG UpdatesProvider Documentation RequirementsMortality ReviewPSIHAC
About the role
Key responsibilities & impact- Perform CDI and coding audits to improve financial and AHRQ quality metrics
- Collaborate with the CDI Education Lead on stakeholder education and provider education materials
- Perform staff, PSI, HAC, HAI, mortality, validation, and special project reviews
- Audit medical records for clinical documentation improvement opportunities
- Conduct real-time audits of reviews, queries, and reports
- Review data and trends to identify improvement opportunities
- Provide feedback and education to CDI teams and coders on documentation and coding best practices
- Review clinical documentation remotely during patient admissions
- Communicate documentation opportunities to physicians
- Perform hospital-wide medical record reviews to improve documentation quality, completeness, accuracy, coding compliance, reporting, and patient outcomes
- Submit compliant electronic queries to clinicians and provide follow-up
- Escalate unanswered queries according to the Wellstar Query Escalation process
- Reconcile records daily in the Solventum/3M 360 Encompass CDI tool
- Maintain daily, weekly, and monthly metrics and meet productivity standards
- Participate in departmental meetings, conference calls, and presentations
- Support hospital compliance with federal and state regulatory requirements
- Review quarterly Coding Clinic changes and update processes accordingly
- Maintain knowledge of coding and billing rules to support appropriate reimbursement
- Perform other duties as assigned
Requirements
What you’ll need- Associate's degree in Nursing, bachelor's degree in Health Science, accredited Health Science program, or doctorate in Medicine
- Clinical Documentation Specialist certification within 180 days or Clinical Documentation Improvement Practitioner certification within 180 days
- Minimum 2 years working in an acute care setting as a Clinical Documentation Specialist
- Minimum 5 years of healthcare experience
- Prior CDI/Coding auditor experience preferred
- Prior inpatient case management or utilization review experience preferred
- RNs must hold an active nursing license upon hire
- Non-clinical/coding candidates must have at least one active/current certification upon hire: CCS, CPC, RHIA, or RHIT
- Strong understanding of disease processes, clinical indications and treatments, and provider documentation requirements
- Familiarity with an encoder and current knowledge of Coding Clinic Guidelines and federal DRG updates for MS and APR
- CDI/Coding chart review experience
- Expert knowledge of Clinical Documentation Integrity, including productivity, quality, education, training, compliance auditing, data analysis, trending, report management, and performance improvement
- Strong communication, critical thinking, time management, training, and peer development skills
- Proficiency with Microsoft Word, Excel, and PowerPoint
- Proficiency with CDI technology tools and data analysis
- Ability to interpret, adapt, and apply guidelines, procedures, and continuous quality improvement initiatives
- Ability to collaborate with medical staff, clinical departments, and facility leadership
- Ability to prepare and maintain records and written reports
- Epic and Solventum/3M 360 Encompass experience preferred
Benefits
Comp & perks- Full-time employment
- Remote work for clinical documentation reviews, audits, and related duties
- Supportive work environment where contributions and ideas are valued
- Opportunity to serve with compassion, pursue excellence, and honor every voice
- Meaningful work improving patient outcomes and healthcare quality
- Professional education and development through stakeholder, CDI team, and coder education