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Clinical Documentation Integrity Specialist

Location

United States

Posted

20 days ago

Salary

$69 / hour

Seniority

Mid Level

No structured requirement data.

Job Description

Clinical Documentation Integrity Specialist

Emanate Health

Role 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) - 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. Qualifications - Bachelor's degree preferred - Minimum of one (1) year 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 Requirements - ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer Benefits - Delivering world-class health care one patient at a time Pay Range $69.00 - $69.00

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