Bay Area Hospital

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CDI Auditor I-Clinical Documentation Improvement-FT-DAYS

at Bay Area Hospital

Posted: 10/7/2019
Job Status: Full Time
Job Reference #: 88416389820

Job Description

Full-Time Position (80 Hours Per Pay Period)

Shift: 0800-1700       Days: Varied

Wages Based Upon Experience

CLOSING DATE: Open Until Filled



Support the organization’s mission, vision and values by adhering to the behavioral standards of Bay Area Hospital.  Comply with all laws and regulations affecting Bay Area Hospital.  Be familiar with and adhere to the Code of Conduct and support the Bay Area Hospital Compliance Program.  Effective communication skills and the ability work effectively with people from various backgrounds are critical.


The CDIA role is complex and requires expert knowledge of clinical care and applicable coding guidelines, as well as an ability to communicate effectively with the clinical care team. Reviews records during patient stay to assure accuracy and integrity in documentation and provides education, as needed.

(Essential job requirements listed in bold)

  • Conducts initial and extended-stay concurrent reviews on all selected admissions for opportunities to clarify documentation in the medical record for accurate reflection of severity of illness
  • Performs follow-up on unanswered queries during the patient stay
  • Conducts education to the medical staff, informally and formally, on the benefits of accurate and complete documentation to assist in maintaining physician buy-in and support
  • Conducts chart reviews
  • Evaluates quality of clinical documentation practices. Collaborates with management on remediation plan when indicated
  • Provides feedback to medical and nursing staff on quality ratings and impact of the program
  • Reviews process and productivity reports and coordinates with manager to adjust prioritization and approach to reviews as needed
  • Audits/queries medical and nursing staff to clarify the documentation as necessary
  • Communicates benefits of complete and accurate documentation to physicians and nursing relating to their daily practice of medicine and operational workflows
  • Other job duties as assigned

Skill / Requirements

(Essential job requirements listed in bold)

  • Demonstrates the ability to use a personal computer and various software programs applicable to the position
  • Demonstrates the ability to operate applicable office equipment
  • Exhibits the ability to deal effectively interdepartmentally and with the public
  • Exhibits the ability to maintain confidentiality, think and act independently with minimal supervision
  • Maintains regular, consistent and punctual attendance at the assigned job location
  • Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization
  • Maintains the ability to be flexible, and prioritizes daily responsibilities
  • Demonstrates an understanding of the importance of and makes an effort to capture all appropriate secondary diagnoses for quality ratings/profiling purposes
  • Knowledge of Care Delivery Systems, disease processes, Medicare reimbursements and guidelines, and clinical knowledge
  • Knowledge of care delivery documentation systems and related medical record documents
  • Knowledge of age-specific needs and the elements of disease processes and related procedures
  • Ability to work with all nursing and physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty on an “as you go” basis
  • Strong broad-based clinical knowledge and understanding of pathology/physiology
  • Additional language fluency may be preferred

(Essential job requirements listed in bold)

  • Licensed to practice as a Registered Nurse in the state of Oregon and/or RHIA
  • BSW or BSN preferred
  • CCDS and/or CCS preferred

(Essential job requirements listed in bold)

  • Acute hospital care experience of 5 years or more
  • 3 years’ discharge planning/case management experience
  • Experience with chart abstraction – core measures, quality reviews, or other
  • Prior experience in hospital or community health agency preferred; prior experience with assigned patient population may be required
  • Previous experience with computer electronic record – both AS400 and Soarian Clinicals



Union Affiliation:  ONA/UFCW dependent upon qualifications/licensure

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position.  They are not intended to be an exhaustive list of all duties, responsibilities and job skills required.