Clinical Documentation Integrity Specialist

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

📋 Description

• The Clinical Documentation Integrity Specialist (CDIS) plays a crucial role in enhancing the quality, completeness, and precision of clinical documentation through ongoing collaboration with providers and other healthcare team members.

• The CDIS is responsible for ensuring that documentation accurately captures the patient's clinical conditions and level of service provided.

• The CDIS engages with providers through discussions and/or compliant queries to rectify any missing, unclear, conflicting, or clinically unsupported diagnoses.

• The position entails the accurate assignment of MS-DRG/APR-DRG, severity of illness (SOI), risk of mortality (ROM), and the identification of relevant clinical indicators such as HACs and PSIs.

• The CDIS employs clinical validation principles and ensures that all 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 guidelines.

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

• Exceptional verbal and written communication skills.

• Strong analytical skills, problem-solving capabilities, 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 coverage.

• Retirement savings plan with employer matching.

• Opportunities for professional development and continuing education.

• Flexible work schedule options.