About this role

Facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team
Ensures 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) 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
ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer

Clinical Documentation Integrity Specialist, Per Diem

Key skills