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UT Health Auditor, Clinical Documentation Improvement in Texas Medical Center-Houston, Texas

Auditor, Clinical Documentation Improvement

Texas Medical Center-Houston, Texas


McGovern Medical School at UTHealth

Requisition #: 210000CQ

Position Summary:

The Clinical Documentation Improvement Auditor (CDIA), working under the direction of the Manager, Clinical Documentation Improvement, is accountable for reviewing patient medical records in the inpatient, outpatient or provider setting to capture accurate representation of the severity of illness, ensure proper coding and facilitate CDI improvement initiatives. The CDIA identifies documentation gaps in the provider record and captures CDI trends. CDIA provides timely provider resources and communication needed to achieve compliant charge capture and optimal documentation practices.

Position Key Accountabilities:

  1. Performs systematic CDI chart audits identifying the most appropriate diagnoses codes reflecting the services performed, identifies additional steps needed to prevent denials and determines if providers require documentation education.

  2. Utilizes CDI queries to clarify clinical documentation risk areas and ensures query compliance.

  3. Works collaboratively with the CDI team to identify risk areas and strategies solutions.

  4. Communicates and resolves CDI issues with providers and other clinic leadership in a timely manner.

  5. Tracks and trends audit and metric data needed for CDI program compliance.

  6. Works with CDI leadership to ensure the creation of needed education material for providers on the CDI program.

  7. Performs other duties as assigned.


One of the following coding certifications is required:

Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician-based (CCS-P).


One of the following documentation certifications is also required:

Certified Documentation Improvement Practitioner (CDIP) certification or Certified Clinical Documentation Specialist (CCDS) certification.

Proficiency in Microsoft Office suite, the ability to abstract data and maintain a database and the ability to audit medical records and maintain high productivity. Outpatient Auditor experience and EPIC experience is preferred.

Minimum Education:

High School Diploma or equivalent

Minimum Experience:

Three years of experience, with a combination of coding and clinical documentation improvement roles located in an outpatient or large provider office setting preferred. May substitute required experience with equivalent years of education beyond the minimum education requirement.

Physical Requirements:

Exerts up to 20 pounds of force occasionally and/or up to 10 pounds frequently and/or a negligible amount constantly to move objects.

Security Sensitive:

This job class may contain positions that are security sensitive and thereby subject to the provisions of Texas Education Code § 51.215

If you are looking for a great healthcare career in Houston, visithttp://go.uth.edu/careers!

University of Texas Health Science Center at Houston (UTHealth)

Established in 1972 by The University of Texas System Board of Regents, The University of Texas Health Science Center at Houston (UTHealth) is Houston’s Health University and Texas’ resource for health care education, innovation, scientific discovery and excellence in patient care. The most comprehensive academic health center in the UT System and the U.S. Gulf Coast region, UTHealth is home to schools of biomedical informatics, biomedical sciences, dentistry, nursing and public health and the John P. and Kathrine G. McGovern Medical School. UTHealth includes The University of Texas Harris County Psychiatric Center, as well as the growing clinical practices UT Physicians, UT Dentists and UT Health Services. The university’s primary teaching hospitals are Memorial Hermann-Texas Medical Center, Children’s Memorial Hermann Hospital and Harris Health Lyndon B. Johnson Hospital.

UTHealth Benefits

UTHealth offers a comprehensive and competitive benefits package. For more information on our benefits programs please refer to the UTHealth Office of Benefits Website.


Equal Employment Opportunity Statement

UTHealth is committed to providing equal opportunity in all employment-related activities without regard to race, color, religion, sex, sexual orientation, national origin, age, disability, genetic information, gender identity or expression, veteran status or any other basis prohibited by law or university policy. Reasonable accommodation, based on disability or religious observances, will be considered in accordance with applicable law and UTHealth policy. The University maintains affirmative action programs with respect to women, minorities, individuals with disabilities, and eligible veterans in accordance with applicable law.