Clinical Documentation Integrity Specialist

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

📋 Description

• Oversee the overall quality, completeness, and accuracy of clinical documentation by engaging with providers and other members of the healthcare team concurrently.

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

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

• Properly assign MS-DRG/APR-DRG codes.

• Assess severity of illness (SOI) and risk of mortality (ROM).

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

• Implement principles of clinical validation.

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

⛳️ Requirements

• A bachelor's degree is preferred.

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

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

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

• Exceptional verbal and written communication skills.

• Strong analytical thinking, problem-solving skills, and meticulous 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 hire or transfer.

🏝️ Benefits

• Comprehensive health insurance plans.

• Retirement savings options with employer contributions.

• Opportunities for professional development and continuing education.

• Paid time off and holidays.