About this role
Role Overview
- complete quality assurance reviews of patient medical records to ensure accurate and complete documentation to reflect the patient’s severity and complexity of illness
- audit records previously reviewed by Customer CDS consultants
- review charts for missed opportunities to capture greater specificity or clarify inconsistencies in the clinical picture of the patient
- evaluate queries posed by the Customer CDS from a compliance perspective
- assess adherence to Customer specific CDI processes/procedures
- review accounts not previously reviewed by Customer CDS to identify opportunities for improvement
- work within Customer systems and e4health Audit software to identify areas of risk, documentation opportunities, identifiable trends, and assist with report writing as appropriate
- interact with the Customer appropriately and other team members
Requirements
- Candidate must possess current ACDIS CCDS or AHIMA CDIP certification
- 3+ years of clinical documentation experience required with an acute care facility required
- 2+ years of CDI auditing experience
- Current RN license or graduate of medical school with 5+ years of acute care experience preferred; Customers may require RN
- Thorough understanding of both MS and APR DRG methodologies and Compliant Query Practices as outlined by ACDIS/AHIMA
- Strong analytical skills to clinically evaluate the medical record
- Ability to independently use multiple computer applications for medical record review along with proficiency utilizing Microsoft products (Excel, Word, Outlook)
- Ability to communicate effectively with e4health management and Customers
- Proficiency with ICD-10-CM and ICD-10-PCS
Benefits
- full benefits package including 401(k) with company match
- medical
- dental
- vision
- life
- short/long-term disability insurance
- PTO policy