Clinical documentation auditor

2 weeks ago

Karachi, Sindh, Pakistan Personic Health Full time 600,000 - 1,200,000 per year

Job Title:
Clinical Documentation Auditor Department: Clinical Informatics Specialist Reports To: Director of
Clinical Informatics Job Type:
Full-time

Location: ONSITE

Timings
: 9am to 5pm

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. Key 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.
• Monitor trends and assist in the development of documentation improvement initiatives.
• Stay current on changes in coding guidelines, payer policies, and compliance requirements.

Qualifications: Education:

• Associate's or Bachelor's degree in Health Information Management, Nursing, or related field (preferred). Experience:
• Minimum 3 years of experience in clinical documentation improvement, coding, or auditing in a healthcare setting.

Licensure/Certification:

• One or more of the following credentials strongly preferred: o RHIA, RHIT, CCS, CCDS, CDIP, RN Skills:
• Strong knowledge of coding guidelines, DRG assignment, and healthcare reimbursement methodologies
• Excellent analytical and communication skills
• Proficiency with EHR systems and audit tools
• Attention to detail and ability to work independently

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