RN Clinical Documentation Integrity Audit and Education

Clinical Documentation Integrity Specialist

Location: Partially Remote- Will support sites within Austin, TX & Waco, TX

Department/Specialty: Clinical Documentation Integrity

Schedule: Full Time | Days | Monday-Friday

Salary: $96,208.99-$134,109.89

Life at Ascension: Where purpose meets opportunity

Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 97,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you'll find an inclusive and supportive environment where your contributions truly matter.

Benefits that help you thrive

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options
• Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance
• Time to recharge: pro-rated paid time off (PTO) and holidays
• Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning
• Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources
• Family support: parental leave, adoption assistance and family benefits
• Other benefits: optional legal and pet insurance, transportation savings and more

How you'll make an impact in this role

• Assess the accuracy, consistency, and compliance of clinical documentation reviews performed by front-line CDS. Supports the professional development of the CDI team and provides provider-facing education to improve clinical documentation practices.
• Perform routine and ad hoc audits of CDI queries, documentation reviews, and EHR entries for compliance with internal standards, industry guidelines, and regulatory requirements.
• Evaluate query appropriateness, clinical evidence, and alignment with coding rules (ICD-10-CM/PCS, UHDDS, CMS).
• Identify trends, variances, and opportunities for improvement in CDI team performance. Maintain internal audit tools, track performance metrics, and present findings to leadership on a regular basis
• Provide one-on-one coaching for new or developing team members, based on audit findings or performance trends. Create and maintain educational materials, tip sheets, and query templates in accordance with evolving CDI best practices.
• Develop and deliver comprehensive CDI education programs, including onboarding, continuing education, and skills refreshers.

What minimum requirements you'll need

Licensure / Certification / Registration:

Required Credential(s): Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.

Education:

High School diploma equivalency with 2 years of cumulative experience OR Associate's/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

What additional preferences we're seeking

• Must have a Certified Clinical Documentation Specialist (CCDS) certification from the Association of Clinical Documentation Improvement Specialists (ACDIS)
• RN license in Texas
• Expert understanding of CDI best practices, DRG methodologies (MS-DRG and APR-DRG), and coding principles
• Strong knowledge of SOI/ROM, MCC/CC capture, risk adjustment, quality indicators (PSI, HAC, mortality), and CMS compliance
• Proficiency with audit tools, EHR systems (e.g., Epic), and CDI software platforms (e.g., Iodine, 3M, Nuance)

Equal employment opportunity employer

Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.

Fraud prevention notice

Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system.

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