Clinical Documentation Auditor

Focus Area 

Typical Tasks 

Chart Auditing 

• Apply ICD10CM, CPT®, HCPCS, and CMS E/M guidelines to 25–35 charts per shift. 
• Perform dual coding and resolve interrater discrepancies within 24 hours. 
• Conduct clinical validation to confirm medical necessity of all up coded services. 

Compliance & Quality 

• Maintain immutable audit logs in the compliance repository. 
• Flag potential upcoding/down coding, cloned notes, and diagnosis procedure mismatches. 
• Achieve ≥ 95 % interrater reliability and ≤ 3 % overall error rate. 

Feedback & Coaching 

• Create chart specific feedback and trend reports for providers and CDI coaches. 
• Participate in 15minute microlearning huddles; share specialty specific insights. 

Data & Reporting 

• Update audit dashboards (Power BI) with accuracy, denial, and turnaround metrics. 
• Support external payer audits by packaging requested documentation within SLA. 

Process Improvement 

• Recommend AI prompt or template refinements to reduce recurring documentation gaps. 
• Contribute to Lean/Six Sigma projects that improve throughput or reduce rework. 

Skill Category 

Specific Competencies 

Coding & Clinical Acumen 

• Mastery of ICD10CM & CPT® conventions, modifiers, HCCs. 
• Ability to interpret clinical terminology across multiple specialties (e.g., ortho, GI, cardiology). 

Analytical & Detail Orientation 

• Detect subtle documentation gaps and pattern anomalies. 
• Root cause analysis of denial trends and coder variance. 

Technology Proficiency 

• Comfortable auditing AI generated notes and suggesting prompt tweaks. 
• Basic SQL or Power Query skills to slice audit datasets (nice to have). 

Communication & Coaching 

• Write concise, constructive feedback that providers will act on. 
• Confident presenting findings on video calls with U.S. clinicians. 

Compliance Mindset 

• Uphold separation of duties (no production based incentives). 
• Protect PHI and follow zero defect documentation standards. 

Time & Self Management 

• Meet 48hour audit turnaround and daily production targets. 
• Adapt to U.S. Central time overlap and rotating specialty queues.