Reviews inpatient clinical records retrospectively to assess documentation accuracy, patient acuity, DRG assignment, severity of illness, mortality risk, and risk adjustment. Works closely with clinical documentation specialists, physicians, and management to identify query opportunities, support compliant coding, and improve documentation quality. This role also helps guide education and process improvements across multidisciplinary teams in an academic medical center setting.
Key Responsibilities
- Conduct retrospective, prebill audits of clinical records to evaluate documentation completeness and accuracy.
- Review DRG assignment, severity of illness, risk of mortality, and risk adjustment factors.
- Identify clinical validation and query opportunities based on audit findings.
- Provide feedback to clinical documentation specialists and multidisciplinary teams.
- Collaborate with management to summarize review status and recommend education or process improvements.
- Serve as a liaison between medical staff, quality, and health information teams.
- Support team effectiveness and individual performance through audit findings and recommendations.
Required
- Bachelor's degree.
- Medical degree (MD or MBBS), foreign medical graduate status, or registered nurse licensure.
- Certification as CCDS, CCS, RHIA, or RHIT.
- Seven to ten years of relevant work experience.
- Strong knowledge of medical terminology and basic to intermediate CDI and coding concepts.
Preferred
- Experience working with physicians on clinical documentation improvement.
- Strong analytic, organizational, and time management skills.
- Advanced proficiency with Microsoft Office.
- Background in audit, quality, or health information workflows.
Benefits & Perks
- Competitive salary.
- Health, dental, prescription, and vision coverage.
- 403(b) retirement plan with company match for eligible employees.
- Paid time off and paid holidays.
- Tuition reimbursement.
- Employee assistance program.
- Long-term disability and life insurance options.
- Onsite day care for eligible employees.
- Federal student loan forgiveness eligibility through the nonprofit health system.