Clinical Document Integrity Lead [AQ-25349]

Aquent; Palo Alto (CA); Presencial; USD 110.000 - 170.000; Jornada completa

Descripción de la vacante

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.

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

CDI experience

MS-DRGs knowledge

Analytical thinking

Communication with clinicians

Educación

BSN or HIM degree

Master’s degree with CDI experience

Herramientas

Epic EHR

3M 360 Encompass

Solventum

Descripción del empleo

Aquent is partnering with a major healthcare organization renowned for its commitment to patient care, cutting-edge research, and academic excellence. This organization is at the forefront of medical innovation, dedicated to improving health outcomes and advancing medical knowledge. Joining this team means contributing to a mission-driven environment where your expertise directly impacts the quality and integrity of patient documentation, playing a crucial role in accurate care representation and strategic healthcare initiatives.

Are you a highly skilled Clinical Documentation Integrity professional ready to make a significant impact? This is an exciting opportunity to leverage your clinical expertise and coding acumen to ensure the precise capture of patient severity of illness, risk of mortality, and complexity of care. You will be a vital liaison, bridging the gap between clinical staff and coding teams, driving accuracy, and contributing to the overall quality of patient records within a world-class academic medical environment. Your work will directly influence patient outcomes, operational efficiency, and the integrity of healthcare data.

Your Impact

• 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 organizational 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 Clinical Documentation Integrity (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.

Required 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.

What Will Set You Apart

• Active Registered Nurse (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.

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)