Clinical Chart Auditor

Clinical Chart Auditor Job Summary TheClinical Chart Auditoris responsible forconducting systematic reviews of patient medical records to ensure clinical documentation integrity and coding accuracy.

This role is essential for minimizing audit risks,optimizingrevenue cycle performance, and supporting regulatory adherencefor retina-specific services.

Remote work options may be available based on operational needs, candidate qualifications, and practice location requirements.

This is a Remote position; however, all candidates considered for this position must currently reside within Central California.

Duties / Responsibilities Perform routine internal chart audits (retrospective,concurrentand prospective) on a representative sample of patient encounters.Verify alignment between clinical documentation, ICD-10 diagnoses, CPT/HCPCS procedure codes, and supporting elements (physician orders, informed consents, medical necessity, etc.).Identify, document, and track documentation deficiencies and compliance gaps (cloned notes, insufficient chief complaints, lack of medical necessity, unsupported level of the office visit CPT, etc.), generating detailed audit reports.Analyze audit findings to produce trended data on clinical documentation integrity accuracy rates and risk areas, presenting actionable insights to leadership, billing, and clinical teams for process improvements.

Collaborate with clinical trainers, billing specialists, scribes and physicians to provide targeted feedback, resolve discrepancies, and deliver education on documentation standards, coding guidelines, and audit best practices.

Monitor key performance indicators (KPIs) for clinical documentation integrity and coding accuracy, contributing to the practice's overall compliance program.

Facilitate MIPS success by gathering and auditing required clinical data and collaborating with the clinical team to implement best practices.Manage prescription drug processes including handling Rx refills, processing prescription drug change requests, and facilitating prior authorizations (PAs) to support timely and accurate medication delivery in coordination with clinical teams.

Other Duties Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.Duties, responsibilities, and activities may change at any time with or without notice.