Clinical Document Integrity Lead [AQ-26017]

Aquent; Palo Alto (CA); On-site; USD 150,000 - 190,000; Full time

Job summary

Aquent partners with a major healthcare organization to place a dedicated clinical documentation professional. You will bridge clinical care and coding, ensuring precise coding of patient severity and treatment complexity to support data integrity and quality outcomes.

This role demands strong CDI experience, Epic proficiency, and collaboration with multidisciplinary teams.

Qualifications

• Bachelor's level degree in Nursing, Medicine, HIM or related field.
• 5+ years inpatient clinical experience.
• 2-5 years CDI experience (or Master’s with 0-2 years CDI).
• Active core CDI/coding certifications (CCDS, CDIP, CCDS-O, CCS, CPC, COC, CRCR, CCM, or CPHQ etc).
• Strong knowledge of MS-DRGs, APR-DRGs, HCCs, ICD-10-CM/PCS coding conventions; familiarity with Epic and CDI software.

Responsibilities

• Review and validate documentation accuracy within 24–48 hours of admission.
• Collaborate with physicians and coding teams to clarify documentation via queries and rounds.
• Assign and validate DRGs per ICD-10-CM/PCS guidelines and CMS rules.
• Review charts for PSIs, HACs and mortality metrics to reflect correct CMI.
• Provide CDI guidance to frontline staff and support education initiatives.
• Track and report CDI metrics across service lines with tracking tools.
• Lead or support CDI improvement projects and workflow enhancements.

Skills

CDI experience

Analytical thinking

Communication with multidisciplinary团队

Education

BSN / HIM / related degree

Tools

3M 360 Encompass / Solventum

Job description

Aquent is partnering with a major healthcare organization renowned for its commitment to patient care, cutting-edge research, and academic excellence to find a dedicated clinical documentation professional. In this vital role, you will have a direct, transformative impact on the integrity of patient care records, bridging the gap between clinical complexity and accurate data representation. By ensuring the precise capture of patient severity and treatment complexity, your expertise will influence quality outcomes, operational efficiency, and strategic healthcare initiatives within a world-class academic medical environment.

The Opportunity

Are you ready to leverage your clinical expertise and coding acumen to elevate healthcare data integrity? We are seeking a highly skilled professional to serve as a key liaison between clinical staff and coding teams. In this dynamic position, you will drive accuracy across patient records, collaborate closely with multidisciplinary healthcare providers, and champion documentation excellence. This is an exciting opportunity to apply your analytical talents in a mission-driven environment where your contributions directly support outstanding patient care and organizational success.

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 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.
• Authorized to work in the United States on a W-2 basis without requiring sponsorship.

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.