Clinical Documentation Auditor

The Clinical Documentation Auditor is responsible for supporting the Care Management team by providing ongoing staff audits to ensure compliance with documentation requirements. Utilizes clinical expertise for the review of patient files and care plans against appropriate criteria in conjunction with accreditation, contract requirements, critical thinking, and decision-making skills to determine medical appropriateness, while maintaining production goals and QA standards. Ensures day-to-day processes are conducted in accordance with NCQA Standards other internal and regulatory standards. The Clinical Documentation Auditor will provide ongoing feedback and education to the clinical management team regarding accurate documentation to improve overall health outcomes for patients and continuity of care.

Essential Functions

• Reviews and interprets patient files and care plans against criteria to determine appropriate documentation based on clinical practice guidelines and appropriateness of care; determines if the patient file documentation supports the patients’ need for services.
• Reviews internal assessments and care plans against NCQA case management and population health standards for timeliness and accuracy of documentation.
• Preparation of the individual staff audit findings, documentation of deficiencies as well as developing final staff reports for clinical management and supervisors of the audited resources.
• Collaborates with clinical management to provide opportunities for improvement regarding patient files and care planning documentation.
• Educates management and team members on adherence procedures.
• Creates and manages review process and support tools.
• Abstracts review related data/information accurately and timely on appropriate review tool by the appropriate means. Accurate and timely submission of all administrative and review related documents to appropriate parties.
• Performs ongoing reassessment of review process to offer opportunities for process improvement and/or change.
• Identifies gaps in clinical software assessments and care plans for compliance with accreditation and regulatory standards.
• Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
• Responsible for attending training, scheduled meetings, and for maintenance and use of current/updated information for review.
• Maintains patient file confidentiality through proper use of computer passwords, maintenance of secured files, adherence to HIPAA polices.
• Actively cross-trains to perform other duties of contractual requirements of Strive Health to provide a flexible workforce to meet client/consumer needs.
• Meet in person with internal and/or external stakeholders to facilitate team and business priorities/opportunities.

Minimum Qualifications

• Active, unrestricted RN license
• 3+ years of experience in documentation, reporting, and auditing in a healthcare or managed care environment
• Business travel
• Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60 ms

Preferred Qualifications

• NCQA Case Management accreditation standards and process experience.
• NCQA Population Health accreditation standards and process experience.
• Strong clinical assessment and critical thinking skills
• Excellent verbal and written communication skills
• Ability to work in a team environment.
• Flexibility and strong organizational skills needed.
• Proficiency in Microsoft Office, Adobe Acrobat and internet/web navigation.
• Care Management Certification
• Bachelor's degree in nursing or another health-related field required; master's in nursing or another health-related field preferred.
• Will substitute 5 or more years of clinical experience along with an associate degree and RN licensure in place of the bachelor’s degree and RN licensure.
• NCQA Accreditation Survey Patient File presentation experience.
• Knowledge of the organization of medical records, medical terminology, and disease process
• Remote experience preferred

Annual Salary Range: $72,800.00-$88,300.00