Clinical Documentation Auditor

Cigma Medical Coding Academy

6 - 8 years

4 - 10 Lacs

cochin kerala india

Posted:1 month ago| Platform: Foundit logo

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Skills Required

icd-10-cm codes documentation diagnosis codes audits billing risk adjustment

Work Mode

On-site

Job Type

Full Time

Job Description

Conduct regular, detailed audits of clinical documentation in medical records to ensure accuracy, completeness, and compliance with ICD-10-CM/PCS, CPT, and DRG guidelines.
Evaluate provider documentation to ensure that the medical necessity is established and coding reflects the severity of illness, risk of mortality, and overall resource utilization.
Identify documentation deficiencies and trends; provide constructive feedback and recommendations for improvement.
Collaborate with CDI specialists, coders, and physicians to clarify documentation and resolve inconsistencies.
Prepare detailed audit reports, including findings, trends, and opportunities for improvement.
Assist in developing and delivering education and training materials for providers and clinical staff regarding documentation standards and best practices
Stay current with coding guidelines, regulatory changes (CMS, Joint Commission, etc.), and industry best practices.
Participate in quality improvement initiatives and support internal and external audits as needed.

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