Medical Coding Auditor

Medical Auditor Clinical Documentation Specialist

Remote | Full-Time

Role Overview:

MedCoded is seeking a detail-oriented and experienced Clinical Documentation Specialist to join our remote team as a Medical Auditor. In this role, you will play a vital part in ensuring the accuracy, completeness, and quality of clinical documentation. Your expertise in medical auditing, technical writing, and analytical skills will help maintain compliance with regulatory standards and improve overall documentation integrity. This is an excellent opportunity for a motivated professional who thrives in an independent, remote work environment and is passionate about healthcare quality and data accuracy.

Key Responsibilities:

• Clinical Documentation Review: Evaluate inpatient and outpatient medical records to ensure proper documentation of diagnoses, procedures, and clinical findings.
• Query Writing: Develop and submit clear, compliant, and well-structured physician queries to clarify ambiguous, conflicting, or incomplete documentation.
• DRG, MCC, and CC Assignment: Accurately assign Diagnosis-Related Groups (DRGs), Major Complications or Comorbidities (MCCs), and Complications or Comorbidities (CCs) according to coding guidelines and clinical documentation.
• Compliance and Quality Assurance: Ensure documentation aligns with ICD-10-CM/PCS, MS-DRG, and APR-DRGcoding systems, as well as CMS and payer-specific requirements.
• Collaboration: Work closely with providers, coders, and clinical teams to enhance documentation practices and support accurate code assignment and reimbursement.
• Education and Training: Provide feedback and education to clinicians on documentation best practices and the importance of complete and accurate recordkeeping.
• Technical Writing: Create clear, precise, and thorough technical documentation for internal audits and reporting.
• Data Analysis: Utilize analytical skills to identify trends, gaps, and opportunities for improving clinical documentation and coding accuracy.

Qualifications:

• Certified Coding Credentials: CCDS, CDIP, CCS, or RHIA/RHIT preferred.
• Experience: Minimum of 3 years in clinical documentation improvement, medical auditing, or inpatient/outpatient coding.
• Technical Skills: Proficient in MS-DRG, APR-DRG, ICD-10-CM/PCS coding, and query development.
• Attention to Detail: Strong ability to identify documentation gaps, inconsistencies, and areas for improvement with a high degree of accuracy.
• Communication: Excellent written and verbal communication skills, with the ability to collaborate effectively across teams.
• Analytical Thinking: Ability to interpret clinical data and provide actionable insights for documentation improvement.
• Independence: Self-motivated, organized, and capable of working efficiently in a remote environment.
• Education: Bachelor’s degree in Health Information Management, Nursing, or a related healthcare field preferred.

Why Join MedCoded?

• Fully Remote: Enjoy the flexibility of working from home.
• Professional Growth: Opportunities for continuing education and certifications.
• Collaborative Culture: Work alongside experienced professionals committed to improving healthcare quality.

Ready to make a difference in clinical documentation integrity? Apply today!

This version expands on responsibilities and qualifications while making the role sound engaging and professional. Let me know if you’d like me to tweak or add anything!