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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 healthcare team members .
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
Inpatient Coding ExperienceClinical Documentation Integrity SpecialistMS-DRG/APR-DRG KnowledgeACDIS Certified Clinical Documentation Specialist (CCDS)AHIMA Certified Documentation Integrity Practitioner (CDIP)
ATS Keywords
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Hard Skills
ICD-10-CM/PCS CodingClinical Validation PrinciplesSeverity of Illness (SOI) AssessmentRisk of Mortality (ROM) AssessmentClinical Indicators IdentificationDocumentation ComplianceEncoder UsageElectronic Health Record (EHR) Systems
Soft Skills
Verbal CommunicationWritten CommunicationAnalytical ThinkingProblem-SolvingAttention to Detail
Tools & Technologies
Microsoft Office Applications
Certifications & Qualifications
ACDIS Certified Clinical Documentation Specialist (CCDS)AHIMA Certified Documentation Integrity Practitioner (CDIP)
Industry Keywords
Clinical DocumentationHealthcare Team CollaborationAHIMA GuidelinesACDIS GuidelinesHACsPSIs
About the role
Key responsibilities & impact- Facilitate the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other healthcare team members
- 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 and assess 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- 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, and 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