Chart Auditor

The Chart Auditor is responsible for reviewing and auditing clinical documentation to ensure accuracy, completeness, and compliance with internal policies, regulatory standards (e.g., DCF, Joint Commission, CARF), and payer requirements. This role plays a critical part in preparing the organization for audits, improving documentation practices, and identifying areas for clinical and administrative improvement.

Key Responsibilities:

Chart Review & Auditing:

• Conduct routine and random audits of patient charts (electronic and/or paper) for IOP and PHP programs in Florida and Tennessee.
• Ensure documentation meets compliance standards for Medicaid, Medicare, commercial insurance, DCF, and Joint Commission.
• Audit for timely and complete clinical entries including assessments, treatment plans, progress notes, discharge summaries, medication logs, and signatures.

Compliance Monitoring:

• Identify documentation errors or omissions and follow up with relevant staff for corrections.
• Track and report recurring compliance concerns and trends to leadership.
• Prepare summaries of audit findings and assist in corrective action planning.
• Maintain detailed records of audits performed and compliance status of each chart.

Training & Support:

• Collaborate with clinical and administrative staff to provide feedback and education on documentation best practices.
• Assist in onboarding new clinicians with training on proper documentation procedures and audit expectations.
• Help prepare documentation for external audits or licensing surveys.

Required Qualifications:

Education & Licensing:

• Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, Nursing, Social Work, or related field (required).
• Certified Professional Medical Auditor (CPMA), Registered Health Information Technician (RHIT), or similar certification preferred but not required.
• HIPAA certification or training preferred.

Experience:

• 2–3 years of experience in behavioral health or substance abuse chart auditing, clinical documentation review, medical records, or compliance.
• Strong knowledge of behavioral health documentation standards, EMR systems, and payer requirements.

Skills & Competencies:

• Excellent attention to detail, organization, and analytical skills.
• Proficient in electronic health record (EHR) systems such as Kipu, Credible, or similar.
• Ability to work independently and maintain confidentiality.
• Strong written and verbal communication skills.

Work Environment:

• Based out of Fort Lauderdale, FL with responsibilities extending to Tennessee operations.
• Remote or hybrid options may be considered for qualified candidates.
• Must be available during standard business hours with occasional flexibility during audits or deadlines.