CDI Lead: Clinical Documentation & Coding Expert

Aquent (United States); Palo Alto (CA); On-site; USD 120,000 - 133,000; Part time

Job summary

Aquent Talent seeks a Clinical Documentation Integrity Specialist in Palo Alto, CA to conduct chart reviews and ensure accurate coding of illness severity, risk of mortality, and care complexity. You will liaise between clinicians and coding teams, using ICD-10-CM/PCS and 3M/Epic tools.

Ideal candidates have a BSN or related degree, 5+ years inpatient experience, and CDI certifications. This is a temporary role with potential to extend or go perm, onsite in Palo Alto.

Qualifications

• Bachelor’s degree in Nursing (BSN), Medicine, Health Information Management (HIM), or closely related field.
• 5+ years of inpatient clinical experience.
• 2–5 years of CDI experience (or Master’s with 0–2 years CDI).
• At least one active core CDI certification (CCDS, CDIP, CCDS-O, CCS, CPC, COC, CRCR, CCM, or recognized Health Care Quality certification).
• Strong knowledge of MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS conventions, and ACDIS/AHIMA ethics for queries.
• Proficiency with Epic and CDI software (3M 360 Encompass / Solventum).

Responsibilities

• Conduct concurrent and retrospective medical record reviews within 24 to 48 hours of admission.
• Collaborate with physicians and coding teams to clarify documentation via formal queries.
• Assign and validate DRGs using ICD-10-CM/PCS guidelines and CMS rules.
• Review charts for focus DRGs, PSIs, HACs, and mortality metrics for CMI accuracy.
• Provide documentation guidance to clinical staff and support education initiatives.
• Track and report CDI activities and metrics using electronic tools.
• Lead or support CDI projects and identify workflow improvements.

Skills

Inpatient clinical experience

CDI experience

Analytical thinking

Communication

Education

BSN or related field

Active CDI certifications (CCDS/CDIP/CCDS-O/CCS/ CPC/ COC/ CRCR/CPHQ)

Tools

Epic EHR

3M 360 Encompass

Solventum CDI software

Job description

Aquent Talent seeks a Clinical Documentation Integrity Specialist in Palo Alto, CA to conduct chart reviews and ensure accurate coding of illness severity, risk of mortality, and care complexity. You will liaise between clinicians and coding teams, using ICD-10-CM/PCS and 3M/Epic tools.

Ideal candidates have a BSN or related degree, 5+ years inpatient experience, and CDI certifications. This is a temporary role with potential to extend or go perm, onsite in Palo Alto.