Clinical Documentation Integrity Specialist

• 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

• 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

Proficiency in Microsoft Office applications preferred