Certified Mental Health Medical Documentation Auditor

The Clinical Documentation Specialist (CDS) or Certified Professional Medical Auditor (CPMA) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS or CPMA collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.

This is a W-2 position requiring 15 hours per week. No benefits will be provided other than a very flexible schedule and the ability to work 100% remotely. Pay is $25-$35 per hour and payroll is monthly, on the 15th of each month.

Essential Functions

• Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
• Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
• Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
• Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
• Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
• Collaborates closely with mental health therapists to ensure accurate diagnostic and procedural data through complete and compliant documentation.
• Leads physician education initiatives, developing strategies to improve documentation practices at the office level and conducting formal training sessions.
• Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
• Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
• Performs other duties as assigned.

Qualifications

• Associate Degree in Nursing, or comparable clinical field (e.g., International MD) required
• Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
• 4-6 years of inpatient and/or outpatient psychiatric hospitalization required
• 3-5 years of billing and/or coding in the mental health field
• 3-5 years of experience in clinical documentation improvement, health information management, or inpatient/outpatient coding preferred
• Experience in physician education or query processes preferred
• Familiarity with regulatory standards and quality metrics related to clinical documentation preferred

Knowledge, Skills and Abilities

• Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
• Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
• Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
• Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
• Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
• Commitment to maintaining compliance with regulatory standards and corporate policies.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure or comparable clinical license (e.g., International MD) required
• CCS-Certified Coding Specialist or ICD-10 certification or trainer designation preferred or
• Certified Clinical Documentation Specialist (CCDS) preferred
• RHIT - Registered Health Information Technician preferred or
• RHIA - Registered Health Information Administrator preferred
• CDIP - Clinical Documentation Improvement Professional preferred or
• Certified Coder-AHIMA or AAPC preferred

Please email your current resume AND cover letter explaining why you are interested in working for Helping Hands Billing Solutions and what sets you apart from your fellow candidates. If you do NOT have mental health experience, PLEASE do not waste each other’s time applying. Also, tell me something unique about yourself that would be fun for me to know about.

You can reach us at barb@helpinghandsbillingsolutions.org. NO PHONE CALLS will be accepted.