Clinical Documentation Integrity Specialist

This is a fully remote position, open to applicants in California.

📋 Description

• Oversee the quality, thoroughness, and precision of clinical documentation by engaging with providers and other members of the healthcare team concurrently.

• Ensure that documentation accurately represents the clinical conditions of patients and the level of services provided.

• Interact with providers through discussions and/or compliant queries to rectify any missing, ambiguous, conflicting, or clinically unsupported diagnoses.

• Assign MS-DRG/APR-DRG and evaluate the severity of illness (SOI) and risk of mortality (ROM).

• Identify relevant clinical indicators, such as HACs and PSIs.

• Implement principles of clinical validation effectively.

• Ensure that queries adhere to AHIMA/ACDIS guidelines and the CDI Code of Ethics.

⛳️ Requirements

• A minimum of one (1) year of experience in inpatient coding and/or as a Clinical Documentation Integrity Specialist within an acute care environment.

• In-depth knowledge of MS-DRG, APR-DRG, and ICD-10-CM/PCS coding standards.

• Experience with encoder and electronic health record (EHR) systems.

• Exceptional verbal and written communication skills.

• Strong analytical skills, problem-solving capabilities, and attention to detail.

• Proficiency in Microsoft Office applications is preferred.

• ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) certification is required within one year of hiring or transferring.

🏝️ Benefits

• Comprehensive health insurance plans.

• Competitive salary and performance-based incentives.

• Opportunities for professional development and continuing education.

• Supportive work environment fostering teamwork and collaboration.