Clinical Documentation Integrity Specialist

Overview 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. Responsibilities Communicate with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses. Assign appropriate 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. Qualifications Bachelor’s degree (or higher) 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. Proficiency in Microsoft Office applications. ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within one year of hire/transfer. #J-18808-Ljbffr