Lead - Inpatient Clinical Documentation Integrity (ICDI)

Mayo Clinic • Phoenix, AZ

18h • $90,605 - $136,011

About The Position

The Lead - Inpatient Clinical Documentation Integrity (ICDI) reviews inpatient and/or outpatient medical records to ensure accurate representation of severity of illness and that clinical documentation supports medical necessity, accurate coding, patient clinical status, risk of mortality, and care complexity. The role uses advanced knowledge of disease processes, medications, and critical thinking to identify documentation gaps and improvement opportunities in concurrent and retrospective documentation. It ensures compliance with regulatory, ethical, legal, and coding standards and collaborates with physicians, coders, case managers, nurses, and other staff to improve documentation quality.

The role serves as an educator and resource for clinical staff, promotes documentation best practices, and acts as a change agent for improved documentation. It may perform ICDI DRG secondary reviews, support audit and denial activities, conduct secondary mortality reviews, and undertake special projects and quality improvement initiatives. The position also applies advanced clinical knowledge and expertise from CCS or CIC certification to assign inpatient codes accurately and uses CRC expertise to validate chronic conditions affecting patient risk scores, reimbursement, risk adjustment, and value-based care.

As a lead, the position provides work direction and assistance to other employees, helps ensure work is completed, participates in orientation and training of new employees, communicates assignments, and serves as a liaison between staff and supervisor. It may initiate counseling regarding work quality, productivity, and team communication for corrective action or performance improvement plans. The role requires independent work and effective collaboration in a dynamic team environment, with flexible hours including evenings and weekends as needed to meet business demands.

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).
• One of the following certifications: AHIMA Certified Coding Specialist (CCS) or AAPC Certified Inpatient Coder (CIC).
• AAPC Certified Risk Adjustment Coder (CRC) 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.

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, accurate coding, patient clinical status, risk of mortality, and care complexity.
• Apply advanced knowledge of disease processes, medications, and critical thinking to identify documentation gaps and improvement opportunities in concurrent and retrospective documentation.
• Ensure compliance with regulatory standards related to documentation, coding, and billing, as well as ethical, legal, and coding standards.
• Collaborate with physicians, coders, case managers, nurses, and other staff to improve documentation quality and coding accuracy.
• Educate and serve as a resource to clinical staff, promoting documentation best practices and clarifying documentation with clinical teams.
• Perform ICDI DRG secondary reviews and support audit and denial-related activities as needed.
• Perform special projects and quality improvement initiatives; conduct secondary mortality reviews as requested.
• Accurately assign inpatient codes using CCS or CIC expertise and review records to validate chronic conditions affecting risk scores and reimbursement using CRC expertise.
• Serve as a timekeeping delegate and liaison between staff and supervisor.
• Communicate information and work assignments, provide work direction and assistance to employees, and ensure work in the area of responsibility is completed.
• Participate in orientation and training of new employees.
• Initiate counseling regarding quality of work, productivity, and team communication for corrective action or performance improvement plans.
• Work flexible hours, including evenings and weekends, as needed to meet business demands.

Benefits

• Multiple medical plan options.
• Dental coverage through Delta Dental or a reimbursement account for flexible coverage.
• Vision plan with a national network.
• HSA and FSAs for eligible expenses.
• Competitive retirement package.
• Competitive compensation and comprehensive benefit plans.
• Continuing education and advancement opportunities.

What This Job Offers

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