Lead - Inpatient Clinical Documentation Integrity (ICDI)

Mayo Clinic • Phoenix, AZ

12d

About The Position

The Lead - Inpatient Clinical Documentation Integrity (ICDI) reviews inpatient and/or outpatient medical records to ensure they accurately represent severity of illness, medical necessity, clinical status, risk of mortality, and complexity of care. The role applies advanced knowledge of disease processes, medications, critical thinking, coding, and risk adjustment to identify documentation gaps and improve concurrent and retrospective documentation while maintaining compliance with regulatory, ethical, legal, coding, and billing standards.

The position collaborates with physicians, coders, case managers, nurses, and other staff to improve documentation quality, clarify records, and promote best practices. It may include ICDI DRG secondary reviews, audit and denial support, secondary mortality reviews, and special projects or quality improvement initiatives. The role also uses CCS or CIC expertise to assign inpatient codes and CRC expertise to identify and validate chronic conditions affecting risk scores and reimbursement.

In its lead capacity, the position provides work direction and assistance, supports orientation and training of new employees, communicates work assignments, serves as a liaison between staff and supervisor, and may initiate counseling regarding work quality, productivity, and team communication. The role requires flexibility to work evenings and weekends as needed to meet business demands. This vacancy is not eligible for sponsorship or visa transfer; Mayo Clinic does not participate in the F-1 STEM OPT extension program.

Requirements

• Associate’s degree and 7 years of experience as an Inpatient Clinical Documentation Improvement Specialist (CDIS), or a bachelor’s degree and 5 years of experience as an Inpatient Clinical Documentation Improvement Specialist (CDIS).
• One of the following certifications: Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS).
• Certified Coding Specialist (CCS) AHIMA certification or Certified Inpatient Coder (CIC) AAPC certification.
• Certified Risk Adjustment Coder (CRC) AAPC certification.
• Excellent written and verbal communication skills.
• Strong teamwork, adaptability, and situational awareness.
• Proficiency in Word, PowerPoint, and Excel.
• Project management and problem-solving skills.
• Strong attention to detail and excellent organizational skills.
• Flexibility with work hours to meet business needs.
• Ability to work independently without close supervision and collaboratively in a dynamic, team-oriented environment.
• Must be able to work flexible hours, including evenings and weekends, as needed.

Nice To Haves

• Familiarity with OneNote, SharePoint, and Copilot.

Responsibilities

• Review inpatient and/or outpatient medical records to ensure accurate representation of severity of illness.
• Validate that clinical documentation supports medical necessity and accurate coding.
• Ensure documentation reflects clinical status, risk of mortality, and complexity of care.
• Identify documentation gaps and opportunities for concurrent and retrospective documentation improvement.
• Ensure compliance with regulatory, ethical, legal, coding, and billing standards.
• Collaborate with physicians, coders, case managers, nurses, and other staff to clarify documentation and improve documentation quality and coding accuracy.
• Educate and serve as a resource to clinical staff on documentation best practices.
• Perform ICDI DRG secondary reviews and support audit- and denial-related activities as needed.
• Perform special projects and quality improvement initiatives; may perform secondary mortality reviews.
• Apply CCS or CIC knowledge to assign inpatient codes in compliance with coding guidelines and support optimal reimbursement.
• Apply CRC knowledge to capture risk adjustment information and identify and validate chronic conditions affecting patient risk scores and reimbursement.
• Serve as timekeeping delegate.
• Initiate counseling regarding quality of work, productivity, and team communication for corrective action or performance improvement plans.
• Act as liaison between staff and supervisor; communicate information and work assignments to others in the unit.
• Provide work direction and assistance to other employees and ensure work in the area of responsibility is completed properly.
• Participate in orientation and training of new employees.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree