Clinician Documentation Auditor & Educator

Job Posting Closing Date: Open until Filled

Where do you belong?

Your career is more than just a job, it's part of your life. Whether you’re a clinician, or non-clinical professional, at USACS you'll feel a sense of connection working with clinicians and office staff who share your interests and values. We want you to love coming to work each day because you believe in what you do and the people with whom you work. We care about your success.

USACS also understands that location is important. We offer career opportunities for clinicians and non-clinical support staff from New York to Hawaii and numerous points in between. Our supportive culture, outstanding benefits and competitive compensation package is best in class.

Job Description

Location: Remote

ESSENTIAL JOB FUNCTIONS:

• Obtains and promotes appropriate clinical documentation through extensive interaction with clinicians and coding staff to ensure that the documentation of the level of service rendered to the patient and the patient’s clinical complexity is complete and accurate.
• Reviews medical records and identifies potential gaps in clinical documentation.
• Queries clinicians via approved coder communication mechanisms to obtain accurate and complete documentation that supports the severity of patient illness, intensity of services and risk of mortality.
• Maintains or exceeds established quality and productivity standards.
• Works closely with coding staff to assure LOS coded was supported by documentation.
• Demonstrates basic knowledge of coding standards and application to ongoing evaluation of medical record documentation.
• Collaborates with other Sr. Clinician Documentation Educator (Sr.,CDE) to develop and implement clinician/coder education based on chart review findings.
• Identifies strategies through data gathering and analysis of trends to establish recommendations for complete, accurate clinical documentation.
• Other duties as assigned

KNOWLEDGE, SKILLS AND ABILITIES:

• Beginning and/or intermediate clinical assessment skills typically gained and maintained through accredited CDI organizations and certification programs.
• Analytic skills and ability to process assigned duties in an organized manner.
• Knowledge of and experience using ICD-10-CM and CPT and HCPCS coding.
• Knowledge of professional coding in specialty of emergency medicine and other specialty service lines
• Knowledge and understanding of multiple electronic medical records
• Knowledge of and skill using personal computers in a Windows environment with an emphasis on Microsoft Office including Word, PowerPoint and Excel.
• Ability to identify, research and solve problems and discrepancies.
• Ability to professionally and effectively communicate speaking in public arenas or in writing with clinicians, coworkers and management.
• Ability to maintain confidentiality.
• Ability to effectively perform in a multi-task work environment.
• Completes work with limited degree of supervision
• Strong organizational skills
• Adaptability – maintaining effectiveness when experiencing major changes in work tasks or the work environment; able to adapt to change in environment and/or circumstances with a positive outlook; and adjusting effectively to work within new work structures, processes, requirements, or cultures
• Initiative – independently takes prompt proactive steps towards problem resolution
• Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations. Cultivates strategic customer relationships and ensures that the customer perspective is the driving force behind all value-added business activities
• PC skills - demonstrate proficiency in software applications

EDUCATION AND EXPERIENCE:

• High school diploma or equivalent.
• RN, RHIT, RHIA, CPC, or CCS-P with CPMA or other job-related accreditation required.
• At least three years of coding experience or equivalent training/education.
• Demonstrated knowledge of industry guidelines and regulations required.

Hourly Rate: $28.54-$52.80

USACS offers a comprehensive and competitive benefits package designed to support the health, well-being, and financial security of our employees.

Benefits may vary based on role, location, and employment status, but generally include:

• Medical, dental, and vision insurance options

• Health savings accounts (HSA) and flexible spending accounts (FSA)

• 401(k) employee and employer contributions

• Paid time off, including vacation, sick leave, and company holidays

• Paid parental leave & family support benefits

• Short-term and long-term disability insurance

• Life and accidental death & dismemberment (AD&D) insurance

• Employee assistance programs & wellness resources

Additional compensation may include bonus eligibility, equity, or other incentive programs, depending on the role.

Specific benefit offerings and eligibility will be provided during the hiring process and may be subject to change in accordance with applicable laws and company policies.