CDI Lead: Elevate Clinical Documentation Integrity

Aquent; Palo Alto (CA); On-site; USD 110,000 - 170,000; Full time

Job summary

Aquent has partnered with a leading healthcare organization to hire a Clinical Documentation Integrity professional. The role focuses on accurate capture of severity of illness, risk of mortality, and complexity of care within an academic medical setting.

You will collaborate with clinicians and coding teams, drive documentation accuracy, and support initiatives that improve patient records, outcomes, and data integrity across service lines.

Qualifications

• Bachelor’s degree in Nursing, HIM, or related field.
• 5+ years inpatient clinical experience.
• 2–5 years CDI experience (or Master’s with 0–2 years CDI).
• One active core CDI certification (e.g., CCDS, CDIP, CCS, CPC).
• Strong knowledge of MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS conventions.

Responsibilities

• Conduct concurrent and retrospective medical record reviews within 24–48 hours of admission.
• Clarify documentation via queries and rounds with physicians and coding teams.
• Assign and validate working DRGs per ICD-10-CM/PCS guidelines and CMS rules.
• Review charts for PSIs, HACs, and mortality to ensure quality and CMI.
• Provide documentation guidance to frontline staff and contribute to education.

Skills

CDI experience

MS-DRGs knowledge

Analytical thinking

Communication with clinicians

Education

BSN or HIM degree

Master’s degree with CDI experience

Tools

Epic EHR

3M 360 Encompass

Solventum

Job description

Aquent has partnered with a leading healthcare organization to hire a Clinical Documentation Integrity professional. The role focuses on accurate capture of severity of illness, risk of mortality, and complexity of care within an academic medical setting.

You will collaborate with clinicians and coding teams, drive documentation accuracy, and support initiatives that improve patient records, outcomes, and data integrity across service lines.