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Clinical Documentation Integrity Specialist
CVHP Project & Development Management. Facilitate the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team.
Core Competencies
Role fitCore Competencies
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Demonstrates expertise in clinical documentation integrity, ensuring accurate representation of patient conditions and compliance with coding guidelines. Proficient in MS-DRG, APR-DRG, and ICD-10-CM/PCS coding, with strong analytical and communication skills.
Highest-signal resume keywords
Clinical Documentation IntegrityMS-DRG CodingICD-10-CM/PCS CodingACDIS Certified Clinical Documentation Specialist (CCDS)Electronic Health Record (EHR) Systems
ATS Keywords
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Hard Skills
Inpatient Coding ExperienceClinical Validation PrinciplesSeverity of Illness (SOI) EvaluationRisk of Mortality (ROM) EvaluationClinical Indicators IdentificationAttention to DetailAnalytical ThinkingProblem-Solving Abilities
Soft Skills
Verbal Communication SkillsWritten Communication Skills
Tools & Technologies
Encoder SystemsMicrosoft Office Applications
Certifications & Qualifications
AHIMA Certified Documentation Integrity Practitioner (CDIP)
Industry Keywords
AHIMA GuidelinesACDIS GuidelinesHACsPSIsCDI Code of Ethics
About the role
Key responsibilities & impact- Facilitate the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team.
- Ensure documentation accurately reflects patients’ clinical conditions and level of service.
- Communicate with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses.
- Assign MS-DRG/APR-DRG appropriately.
- Evaluate severity of illness (SOI) and risk of mortality (ROM).
- Identify relevant clinical indicators, including HACs and PSIs.
- Apply principles of clinical validation.
- Ensure queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics.
Requirements
What you’ll need- Bachelor's degree 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.