Clinical Documentation Auditor

Position Summary:

The Clinical Documentation Auditor is responsible for reviewing clinical documentation to ensure accuracy, completeness, and compliance with regulatory and coding requirements. This role plays a critical part in supporting accurate coding, improving quality measures, and ensuring the integrity of patient records.

Responsibilities:

• Perform detailed audits of clinical documentation to assess compliance with organizational policies, CMS, and regulatory standards.

• Review inpatient and/or outpatient medical records to evaluate accuracy of diagnosis and procedure coding (ICD-10-CM, ICD-10-PCS, CPT).

• Identify documentation gaps and work collaboratively with providers, coders, and CDI staff to resolve discrepancies.

• Provide feedback, education, and recommendations to clinical staff to improve documentation practices.
• Maintain accurate records of audit findings and prepare reports for leadership.