Inpatient Clinical Documentation Integrity (CDI) Auditor
Position Summary
The Inpatient CDI Auditor is responsible for conducting detailed audits of clinical documentation and DRG assignments to ensure accurate, complete, and compliant records that reflect the true acuity of the patient and the resources used. This role serves as a vital checkpoint in validating the integrity of CDI practices and DRG assignments, identifying opportunities for improvement, and supporting revenue cycle, quality reporting, and compliance initiatives.
Schedule
Monday- Friday
10 hour days, with one flex day per week
Key Responsibilities
Audit & Review:
• Conduct retrospective and/or concurrent audits of inpatient medical records to verify clinical documentation and DRG coding accuracy.
• Identify documentation deficiencies, missed diagnoses, and unsupported clinical indicators that impact reimbursement, quality scores, or compliance.
• Capability to evaluate queries and their impacts
• Use software tools (e.g., 3M, Optum, Iodine, Epic-Cerner, or Meditech-based systems) to cross-check queries, code assignments, and DRG groupers.
Compliance & Quality Control:
• Ensure all queries are compliant with AHIMA, ACDIS, and CMS guidelines (e.g., no leading queries).
• Evaluate the alignment of documentation with Official Coding Guidelines, Coding Clinics, and payer requirements.
• Monitor trends for potential upcoding, downcoding, or missed HCC capture opportunities.
Education & Feedback:
• Based on audit findings, provide written feedback and coaching to CDI specialists, coders, and physicians.
• Collaborate with CDI educators to develop targeted training based on recurring audit findings.
• Participate in internal peer review and quality assurance processes to uphold CDI team standards.
Reporting & Metrics:
• Prepare detailed audit reports, including case-level findings, error types, recommendations, and summary metrics (e.g., accuracy rate, MCC/CC capture, DRG mismatch rate).
• Track performance trends over time and provide monthly summaries to leadership.
• Help support CMS Star Rating goals, GMLOS integrity, and Case Mix Index enhancement.
Qualifications
Education
• Medical Doctor, Registered Nurse (RN), Advanced Practice Provider (NP/PA); a Bachelor’s Degree is required, while a master’s in nursing, Health Information Management (HIM), or Healthcare Administration is preferred
• One of the following certifications is required:
• CCDS (Certified Clinical Documentation Specialist)
• CDIP (Clinical Documentation Improvement Practitioner)
• CCS (Certified Coding Specialist)
Experience
• Minimum of 3 years of recent experience in CDI, coding, or inpatient case auditing.
• Experience in an acute care or academic healthcare settings is highly desirable.
• Familiarity with hospital quality and value-based care metrics is a plus.
Job Types: Contract, Temporary
Pay: Up to $46.00 per hour
Benefits:
• Paid time off
Work Location: Remote
Apply Now
Apply Now
The Inpatient CDI Auditor is responsible for conducting detailed audits of clinical documentation and DRG assignments to ensure accurate, complete, and compliant records that reflect the true acuity of the patient and the resources used. This role serves as a vital checkpoint in validating the integrity of CDI practices and DRG assignments, identifying opportunities for improvement, and supporting revenue cycle, quality reporting, and compliance initiatives.
Schedule
Monday- Friday
10 hour days, with one flex day per week
Key Responsibilities
Audit & Review:
• Conduct retrospective and/or concurrent audits of inpatient medical records to verify clinical documentation and DRG coding accuracy.
• Identify documentation deficiencies, missed diagnoses, and unsupported clinical indicators that impact reimbursement, quality scores, or compliance.
• Capability to evaluate queries and their impacts
• Use software tools (e.g., 3M, Optum, Iodine, Epic-Cerner, or Meditech-based systems) to cross-check queries, code assignments, and DRG groupers.
Compliance & Quality Control:
• Ensure all queries are compliant with AHIMA, ACDIS, and CMS guidelines (e.g., no leading queries).
• Evaluate the alignment of documentation with Official Coding Guidelines, Coding Clinics, and payer requirements.
• Monitor trends for potential upcoding, downcoding, or missed HCC capture opportunities.
Education & Feedback:
• Based on audit findings, provide written feedback and coaching to CDI specialists, coders, and physicians.
• Collaborate with CDI educators to develop targeted training based on recurring audit findings.
• Participate in internal peer review and quality assurance processes to uphold CDI team standards.
Reporting & Metrics:
• Prepare detailed audit reports, including case-level findings, error types, recommendations, and summary metrics (e.g., accuracy rate, MCC/CC capture, DRG mismatch rate).
• Track performance trends over time and provide monthly summaries to leadership.
• Help support CMS Star Rating goals, GMLOS integrity, and Case Mix Index enhancement.
Qualifications
Education
• Medical Doctor, Registered Nurse (RN), Advanced Practice Provider (NP/PA); a Bachelor’s Degree is required, while a master’s in nursing, Health Information Management (HIM), or Healthcare Administration is preferred
• One of the following certifications is required:
• CCDS (Certified Clinical Documentation Specialist)
• CDIP (Clinical Documentation Improvement Practitioner)
• CCS (Certified Coding Specialist)
Experience
• Minimum of 3 years of recent experience in CDI, coding, or inpatient case auditing.
• Experience in an acute care or academic healthcare settings is highly desirable.
• Familiarity with hospital quality and value-based care metrics is a plus.
Job Types: Contract, Temporary
Pay: Up to $46.00 per hour
Benefits:
• Paid time off
Work Location: Remote
Apply Now
Apply Now