Clinical Documentation Specialist

Job Description

Position Title: Clinical Documentation Auditor
Location: Metro Manila / Greater Manila Area, Philippines (hybrid)
Department: Documentation Audit & Compliance
Reports to: Coding Manager – PH Operations
Employment Type: Fulltime | Exempt

Role Summary

As part of Neolytix’s Documentation Audit Program, the Clinical Documentation Auditor reviews AIgenerated (NeoScribe™) and providerentered encounter notes to verify coding accuracy, clinical validity, and regulatory compliance. You will perform concurrent and retrospective audits, deliver actionable feedback to providers and coders, and safeguard clients against payer takebacks and OIG findings.

Key Responsibilities

Focus Area

Typical Tasks

Chart Auditing

• Apply ICD10CM, CPT®, HCPCS, and CMS E/M guidelines to 25–35 charts per shift.
• Perform dual coding and resolve interrater discrepancies within 24 hours.
• Conduct clinical validation to confirm medical necessity of all upcoded services.

Compliance & Quality

• Maintain immutable audit logs in the compliance repository.
• Flag potential upcoding/downcoding, cloned notes, and diagnosisprocedure mismatches.
• Achieve ≥ 95 % interrater reliability and ≤ 3 % overall error rate.

Feedback & Coaching

• Create chartspecific feedback and trend reports for providers and CDI coaches.
• Participate in 15minute microlearning huddles; share specialtyspecific insights.

Data & Reporting

• Update audit dashboards (Power BI) with accuracy, denial, and turnaround metrics.
• Support external payer audits by packaging requested documentation within SLA.

Process Improvement

• Recommend AIprompt or template refinements to reduce recurring documentation gaps.
• Contribute to Lean/Six Sigma projects that improve throughput or reduce rework.

Required Qualifications

• Education: Associate’s or Bachelor’s degree in Nursing, Health Information Management, or equivalent clinical discipline.
• Certification (at least one active): CPC, CCS, COC, CIC, RHIA/RHIT, or CCDS.
• Experience: 3 + years U.S. professional fee and/or facility coding, including at least 1 year in a formal audit or QA capacity.
• Regulatory Knowledge: Deep familiarity with CMS E/M 2023+ guidelines, HCC risk adjustment, OIG CPG, HIPAA privacy & security.
• Technical: Handson with at least one major EHR (Epic, athenahealth, eClinicalWorks) and an encoder (3M, TruCode, Optum). Excel pivot tables; comfort navigating BI dashboards.
• Language: Excellent written and spoken English (minimum CEFR C1).

Essential Skill Sets

Skill Category

Specific Competencies

Coding & Clinical Acumen

• Mastery of ICD10CM & CPT® conventions, modifiers, HCCs.
• Ability to interpret clinical terminology across multiple specialties (e.g., ortho, GI, cardiology).

Analytical & Detail Orientation

• Detect subtle documentation gaps and pattern anomalies.
• Rootcause analysis of denial trends and coder variance.

Technology Proficiency

• Comfortable auditing AIgenerated notes and suggesting prompt tweaks.
• Basic SQL or Power Query skills to slice audit datasets (nicetohave).

Communication & Coaching

• Write concise, constructive feedback that providers will act on.
• Confident presenting findings on video calls with U.S. clinicians.

Compliance Mindset

• Uphold separationofduties (no productionbased incentives).
• Protect PHI and follow zerodefect documentation standards.

Time & SelfManagement

• Meet 48hour audit turnaround and daily production targets.
• Adapt to U.S. Centraltime overlap and rotating specialty queues.

Compensation & Benefits (guideline)

• Base salary: ₱40 000 – ₱65 000 per month, adjusted for certification mix and inpatient specialty expertise.
• Nightdifferential: 10 % of base for shifts past 10 p.m.
• Performance bonus up to 10 % tied to accuracy & TAT KPIs.
• HMO for employee + 2 dependents on Day 1; annual certification renewal subsidy.

Application Instructions

Email your résumé, proof of active certification, and a onepage summary of your most challenging audit case to careers@neolytix.com (cc ronel@neolytix.com) with the subject line “Documentation Auditor – PH.”

Join Neolytix and help ensure that AIpowered clinical documentation is accurate, compliant, and auditproof for providers across the United States.

Job Type: Full-time

Pay: Php40,000.00 - Php65,000.00 per month

Benefits:

• Health insurance
• Opportunities for promotion
• Promotion to permanent employee

Schedule:

• 8 hour shift
• Monday to Friday
• Night shift

Supplemental Pay:

• 13th month salary
• Commission pay
• Overtime pay
• Performance bonus

Work Location: In person