Clinical Document Integrity Lead

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 is partnering with a major Healthcare company to find a Clinical Documentation Integrity Specialist for a temporary opportunity that has the potential to extend or go perm. In this role, you will leverage your clinical expertise and coding acumen to conduct concurrent and retrospective chart reviews that accurately capture patient severity of illness, risk of mortality, and complexity of care. This is an exciting opportunity to serve as a vital liaison between clinical staff and coding teams within a world-class academic medical environment in Palo Alto.

To be considered for this role, you must:

• Be authorized to work in the United States
• Not require sponsorship of any kind for the duration of the assignment
• Be able to work on a W-2 basis (C2C or 1099 is not permitted for this position)

Key Responsibilities

• Conduct clinically based concurrent and retrospective medical record reviews within 24 to 48 hours of admission to assess documentation accuracy, compliance, and clinical specificity.
• Collaborate closely with physicians, advanced practice providers, and inpatient coding teams to clarify ambiguous, incomplete, or conflicting documentation via formal queries and rounding.
• Assign and validate working DRGs utilizing official ICD-10-CM/PCS coding guidelines, AHA Coding Clinic advice, CMS regulations, and hospital policies.
• Review patient charts targeting focus DRGs, Patient Safety Indicators (PSIs), Hospital-Acquired Conditions (HACs), and mortality metrics to ensure appropriate quality outcomes and Case Mix Index (CMI) representation.
• Provide documentation guidance and feedback to frontline clinical staff, assisting in departmental education and performance improvement initiatives.
• Track, reconcile, and report query activities and CDI metrics across assigned service lines using electronic documentation tracking tools.
• Lead or support clinical documentation integrity projects and identify workflow or process enhancements within assigned specialty units.

Requirements & Qualifications

• Bachelor’s degree in Nursing (BSN), Medicine, Health Information Management (HIM), or a closely related field of study.
• 5+ years of progressively responsible and directly related inpatient clinical experience.
• 2–5 years of dedicated Clinical Documentation Improvement/Integrity (CDI) experience (or a Master’s degree with 0–2 years of CDI experience).
• At least one active core certification: CCDS, CDIP, CCDS-O, CCS, CPC, COC, CRCR, CCM, or recognized Health Care Quality certification (CPHQ, HACP, HCQM).
• Strong working knowledge of MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS coding conventions, and ACDIS/AHIMA ethical query standards.
• Demonstrated proficiency with electronic health records (Epic) and CDI software (3M 360 Encompass / Solventum).
• Proven analytical and critical thinking skills with the ability to translate complex coding and documentation concepts for multidisciplinary healthcare teams.
• Ability to work onsite in Palo Alto, CA.

Preferred Qualifications

• Active California Registered Nurse (CA‑RN) license or advanced clinical degree (NP, PA, MD).
• Prior clinical and CDI experience within an Academic Medical Center, ICU, or Emergency Department setting.
• Additional secondary certifications across Revenue Cycle, Coding, Quality, or Project Management.
• Hands‑on experience with Vizient clinical data and mortality review methodologies.
• Background in case management, utilization review, and leading provider documentation education.

The target hiring compensation range for this role is $87.07–$96.74/hr. Compensation is based on several factors including, but not limited to education, relevant work experience, relevant certifications, and location.

About Aquent Talent:

Aquent Talent connects the best talent in marketing, creative, and design with the world’s biggest brands. Our eligible talent get access to amazing benefits like subsidized health, vision, and dental plans, paid sick leave, and retirement plans with a match. We also offer free online training through Aquent Gymnasium. More information on our awesome benefits!

Aquent is an equal-opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics. We’re about creating an inclusive environment—one where different backgrounds, experiences, and perspectives are valued, and everyone can contribute, grow their careers, and thrive.