Clinical Documentation Integrity Quality Auditor

VH Health Information Management - 107181 Winchester, Virginia Full-Time (Primarily Day Shifts)

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Please Note: To protect our patients, our workforce and our community, Valley Health is requiring that all newly hired employees and internal transfers (current employees requesting internal transfers) must have received at least one COVID-19 vaccination dose. Newly hired Applicants (those not currently employed by Valley Health) who have been offered a position will have to provide documentation of their vaccination status at the time of their Employee Health appointment. For internal transfers, Employee Health will contact you if they have questions around your vaccination status. Valley Health has a process for applicants who have been offered a position to request an exemption or deferral for medical or religious reasons. To search for vaccine locations, visit


  • Entity: Valley Health Corporate
  • Shift: Day

Who We Are

Valley Health System is a not-for-profit network of hospitals, urgent cares, physician practices, and services. Expanding across Virginia, West Virginia, and Maryland, we are devoted to the health of all who call our 18-county area home.

A vital resource for healthcare, we are the region’s largest employer, a dependable community partner, and are at the leading edge of clinical innovations.

We are looking for passionate, innovative, and caring people who will each bring their unique skills and perspectives to our workplace.

What You Will Do:

The Clinical Documentation Integrity Quality Auditor is a Registered Nurse with a broad clinical knowledge base around the quality drivers of health care and a thorough understanding of documentation requirements that support the assignment of Diagnosis Related Groups (DRG), Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI), and Present on Admission (POA) indicators. The Clinical Documentation Integrity Quality Auditor has a strong understanding of how clinical documentation drives publicly reported databases, and will conduct concurrent and retrospective medical record reviews for defined patient populations to identify opportunities to improve the overall accuracy of provider documentation. The Clinical Documentation Integrity Quality Auditor has constant interaction with physicians, allied health providers, clinical documentation integrity staff, coding staff, as well as other various health system departments.
The Clinical Documentation Integrity Quality Auditor will be responsible for ? Driving quality improvement initiatives impacting core clinical processes and patient care in conjunction with the leadership of the Clinical Documentation Integrity and Quality Departments. ? Providing guidance and resolution follow-up to multidisciplinary teams to investigate documentation quality issues in real time. Works collaboratively with physicians, managers, administrators, and executive leadership to identify and improve any quality and patient safety issues identified. ? Organizing task forces, reviewing of evidenced based literature, establishing indicators for monitoring and tracking/trending performance. The position will also be expected to: ? Communicate effectively with all levels of internal and external personnel. ? Perform clinical validation review and query initiation for all Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI) identified preferably during concurrent reviews or identified during final code assignment. ? Perform clinical validation review, query initiation, and final code assignment review of any patient populations known to be high risk Diagnosis Related Groups (DRG). ? Maintain knowledge of Clinical Documentation Integrity review processes and software that are used to establish appropriate DRG, MCC, CC, and POA assignment. ? Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation. ? Compile, analyze, and evaluate clinical documentation reports to identify opportunities for education and process improvement for physicians, allied health providers, clinical documentation integrity staff and coding staff. ? Develop and present education materials to different levels of staff including physicians. ? Participate in the development of physician query and other documentation templates that support clinical validation and quality data findings. ? Identify opportunities to impact case mix and documentation based quality outcomes by improving the accuracy of the documentation of complications and co-morbidities. ? Function as an expert resource for CDI and Coding staff on documentation based quality outcomes. This is accomplished by having advanced knowledge of quality database inclusion and exclusion criteria. ? Attend medical staff and other various health system meetings to present clinical documentation trends and quality outcome findings. ? Serve as a liaison between Quality and CDI/Coding. ? Perform quality chart reviews on certain cases with quality indicators. ? Perform other related job duties as assigned.

What You Will Bring:


Bachelors Nursing (BSN) required

A minimum of 5 years of experience as a Registered Nurse required.
Acute care experience preferred.
Minimum of 1 year experience in a clinical/organizational improvement related role, quality review role, Clinical Documentation Integrity role, or a related health care data outcomes role required with demonstrated skills in communication, facilitation, and problem solving.

Certification & Licensures
Current license to practice professional nursing in the Commonwealth of Virginia required

Ability to demonstrate a broad clinical knowledge base necessary to review a wide variety of medical records required
Demonstrated excellent written and oral communication skills required
Ability to precept and mentor Clinical Documentation Integrity staff in quality data management and analysis required
Proven experience building successful physician relationships required
Proficiency with Microsoft Office Suite
Proficiency with computerized encoder, computer assisted coding, and CDI technology

What You Will Get:

- Competitive salary
- Flexible scheduling
- Health Insurance
- Paid Time Off
- Wellness Program
- Tuition Assistance
- Retirement Plan
- Life Insurance

*some benefits are subject to change due to job status

We celebrate, support, and thrive on our differences for the benefit of our employees, our patients, and the communities we serve.
We are neighbors caring for neighbors, and our goal is always to help those we serve get well, feel well, and stay well.


Criminal Background Checks
VA State Police
3rd party Background Check

FLSA Classification


Physical Demands
20 A Nursing, Certified Nursing Assistants (CNA), Patient Care Tech.