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Clinical Documentation Quality Improvement Auditor

Job Summary:    

Improve the overall coding and DRG accuracy through enhancing clinical documentation and improving the quality of patient data utilizing a pre-bill review process (prior to bill submission for payment, the auditor performs coding and DRG assignment and quality reviews on inpatient records within 5 days of discharge and before billing occurs) and/or monthly post discharge quality audits on inpatient and outpatient cases.  This role is vital in supporting the validity and accuracy of ICD-10 coding, MS-DRG, APR-DRG (SOI, ROM), PSI, POA, HAC assignment, mortality O/E ratios (and PPR, PPC, if/when applicable) in compliance with all Federal and State coding regulations and reporting requirements and also works collaboratively with CDI, Coding, physicians, quality and other key hospital personnel to ensure proper quality reporting of data.

Essential Values-Based Competencies:   Demonstrates values-based competencies in line with the four core values that are the foundation of all activities performed by employees to achieve the Mission of the St.

Joseph Health System   (see attached behavioral definitions of competencies):

    Dignity: Demonstrates competence in communication and interpersonal relations.

    Excellence: Demonstrates competence in continuous improvement, continuous learning, accountability, and teamwork.

    Service: Demonstrates competence in customer/patient focus and adaptability.

    Justice: Demonstrates competence in community orientation and stewardship.

Essential Functions:  
• Facilitates appropriate clinical documentation to ensure that the overall quality, level of services, severity of illness, and acuity of care are accurately reflected in a complete medical record, yielding the appropriate reimbursement for the level of services rendered and resources consumed. 
• Essential in supporting the Hospital Value-Based Purchasing (VBP) results, by reviewing documentation to ensure accuracy in the Potentially Preventable Readmissions (PPR), Patient Safety Indicators (PSI), Hospital Acquired Conditions (HAC), Present on Admission (POA) conditions, and Mortality reviews to avoid penalties associated with lack of proper documentation.
• Maintain dynamic communication with coders and CDI personnel to identify root cause of CDI-Coder final DRG mismatch and seek to resolve incongruence with appropriately assigned final DRG. 
• Analyze provider data in concurrence with the CDI Physician Educator, looking for individual, group, and peer outlier trends that could benefit from additional education.

Convey support and education as needed to providers focused on improving processes and the quality of their documentation on a case-by-case basis to accurately reflect patient care in the medical record.
• Works collaboratively with Quality department to not only improve documentation for quality reporting, but to report on trends associated with documentation to ensure continued improvement...