Jefferson Health
Clinical Documentation Audit Specialist
Montgomery County, PA · Full-time · Posted Jul 22, 2026
- Experience
- Minimum 2 years of clinical documentation improvement experience; minimum 3 years of hands-on clinical experience, or 5 years of inpatient acute care medical coding experience in lieu of clinical experience.
- Education
- Bachelor of Science in Nursing, medical graduate degree, bachelor’s degree in Health Information Management or related field, or 4 years of related clinical experience in lieu of a bachelor’s degree.
About the job
Conducts expert clinical documentation reviews and audits to improve the accuracy, completeness, and compliance of clinical and quality reporting across the enterprise.
What you'll do
- Review medical records and perform second-level quality reviews, including mortality, Patient Safety Indicator, and sepsis reviews.
- Write compliant provider queries and support timely query follow-up for discharged cases awaiting final billing.
- Conduct quarterly CDI specialist audits and contribute to documentation improvement, education, and workflow initiatives.
What they ask for
- Working knowledge and experience with clinical record reviews, 3M encoder coding systems, DRG systems, and Epic EHR.
- Expert knowledge of ICD-10 diagnosis and procedural coding conventions and severity of illness/risk of mortality.
- Certified Clinical Documentation Specialist (CCDS) or Clinical Documentation Improvement Practitioner (CDIP) certification.
- Bachelor’s degree in nursing, medicine, health information management, or a related field, or 4 years of related clinical experience in lieu of a bachelor’s degree.
Nice to have
- Prior quality record review experience; hospital-acquired conditions, patient safety indicators, and risk adjustment methodology experience.
- Prior presentation and educational training skills; successful completion of Vizient Risk Adjustment Training.
Tools
3M encoder coding systems, DRG, Epic EHR, ICD-10, Microsoft Office, Outlook, Word, Excel
Model-written summary · the original posting is authoritative