Clinical Documentation Auditor

Position Summary

Performs advanced clinical documentation reviews to ensure the accuracy, completeness, and integrity of the medical record in support of quality outcomes, reimbursement, and regulatory compliance. Responsible for second-level review of complex cases, including mortality reviews, denial validation, and PSI/HAC review. Identifies documentation gaps, validates clinical accuracy, and trends risk patterns across the organization.

Collaborates with CDI leadership and interdisciplinary partners to support a continuous feedback model that promotes documentation improvement and reduces organizational risk. Education, Licensure & Certifications Bachelor of Science in Nursing (BSN) required; Master’s degree preferred CCDS certification required Experience Requirements Prior CDI experience required with a minimum of 3–5 years in CDI, including advanced review experience.

Minimum of 5 years clinical experience in an acute care setting required. Experience with mortality review, denial management, clinical validation, and DRG integrity strongly preferred. Requires strong analytical, critical thinking, and problem-solving skills. Must demonstrate ability to evaluate complex clinical scenarios and identify documentation and coding inconsistencies.

Essential Functions

Performs second-level clinical documentation reviews, including retrospective and concurrent evaluation of complex inpatient cases. Conducts comprehensive mortality reviews to validate documentation accuracy, risk adjustment (SOI/ROM), and alignment with coded outcomes. Identifies opportunities impacting observed versus expected (O/E) mortality performance.

Reviews payer denials to assess clinical validity, documentation support, and DRG integrity. Identifies root causes and trends to support denial prevention and appeal strategies. Performs focused review of Patient Safety Indicators (PSIs) and Hospital-Acquired Conditions (HACs) to ensure accurate documentation and alignment with reported outcomes.

Validates clinical diagnoses and documentation to ensure compliance with coding guidelines, clinical validation standards, and regulatory requirements. Identifies and trends documentation risks, gaps, and opportunities across mortality, denials, PSI/HAC, and high-risk clinical scenarios. Provides structured insights and recommendations to support performance improvement initiatives and program development.

Collaborates with CDI, Coding, Quality, and Revenue Cycle teams to resolve discrepancies and improve documentation integrity. Supports the development of appeal rationale and documentation strategies for complex or disputed cases. Maintains current knowledge of coding guidelines, clinical validation expectations, and regulatory requirements.

Participates in process improvement initiatives to enhance documentation accuracy, reduce denials, and improve quality outcomes. Other Duties: Participates in departmental and organizational committees and task forces. May travel to other Guthrie entities as needed. Performs other duties as assigned. update 10-5-26