Clinical Documentation Integrity Specialist - Full Time (On-Site) - Days - 8hr QVH
About The Position
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.
Requirements
- Bachelor's degree required.
- 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.
- ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer.
Nice To Haves
- Proficiency in Microsoft Office applications preferred.
Responsibilities
- Facilitate the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team.
- Ensure that documentation accurately reflects the patient’s clinical conditions and level of service.
- Communicate with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses.
- Appropriately assign MS-DRG/APR-DRG, severity of illness (SOI), risk of mortality (ROM), and identify relevant clinical indicators (e.g., HACs, PSIs).
- Apply principles of clinical validation and ensure all queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics.
Benefits
- Health insurance
- Dental insurance
- Vision insurance
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
