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Clinical Documentation Integrity Specialist

United States, West Covina 42.80 - 66.34 USD / Hour · Job Posted January 16, 2026
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Job Description

The Clinical Documentation Integrity Specialist (CDIS) facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team. The CDIS ensures that documentation accurately reflects the patient’s clinical conditions and level of service. The CDIS communicates with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses. The role includes appropriate assignment of MS-DRG/APR-DRG, severity of illness (SOI), risk of mortality (ROM), and identification of relevant clinical indicators (e.g., HACs, PSIs). The CDIS applies principles of clinical validation and ensures all queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics.

Job Responsibility

  • Facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team
  • Ensures that documentation accurately reflects the patient’s clinical conditions and level of service
  • Communicates with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses
  • Includes appropriate assignment of MS-DRG/APR-DRG, severity of illness (SOI), risk of mortality (ROM), and identification of relevant clinical indicators (e.g., HACs, PSIs)
  • Applies principles of clinical validation and ensures all queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics

Requirements

  • Medical degree or Bachelor of Science in Nursing (BSN) required
  • Minimum of three (3) years of inpatient coding experience and/or experience working as a Clinical Documentation Integrity Specialist in an acute care setting
  • Strong knowledge of MS-DRG, APR-DRG, ICD-10- CM/PCS coding guidelines
  • Experience using encoder and electronic health record (EHR) systems
  • Excellent verbal and written communication skills
  • Strong analytical thinking, problem-solving abilities, and attention to detail
  • Proficiency in Microsoft Office applications preferred
  • ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required

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