Ensures accurate, complete, and compliant clinical documentation that appropriately reflects severity of illness, risk of mortality, and supports correct reimbursement.
Partners closely with providers, coding teams, and practice participants to drive documentation quality, regulatory compliance, and value-based care initiatives.
Develops and implements standard processes, job aids, and error prevention tools to strengthen clinical documentation integrity across participating practices.
Educates providers and office staff on best-practice clinical documentation standards to ensure accuracy, completeness, and compliance.
Conducts prospective and retrospective reviews and prepares analyses and reports to identify trends, gaps, and improvement opportunities.
Provides guidance and consultation to internal practice staff to improve coding proficiency and documentation accuracy.
Collaborates with population health and practice teams to support quality programs, value-based initiatives, and standardized data abstraction processes.
Advises practice staff on compliance with applicable federal, state, and local regulations related to Medicare coding and documentation guidelines.

Bachelor’s degree in a related field.
Minimum of 5 years of experience in Clinical Documentation Integrity (CDI) or coding
At least 3 years of experience supporting healthcare value-based programs, including Medicare Risk
At least one required certification, such as CPC, CRC, CCS‑P, CCS‑H, RHIT, CCDS, or CDIP
Advanced knowledge of ICD‑10 coding guidelines and clinical documentation standards
Strong understanding of CMS quality programs, HCCs, value‑based care models, and EHR systems
Excellent written, verbal, interpersonal, and presentation skills
Advanced proficiency in Microsoft Office applications (Excel, Word, PowerPoint, Outlook)
Strong critical thinking, problem‑solving, and time‑management skills

Senior Clinical Documentation Integrity Specialist

Key skills