Clinical Documentation Integrity Specialist

Midland-Marvel Recruiters, LLC; Los Angeles (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Midland-Marvel Recruiters, LLC is seeking a CDI Specialist for a community hospital in Los Angeles. The role focuses on improving the quality, completeness and accuracy of clinical documentation, working with providers to clarify diagnoses, and ensuring accurate MS-DRG/APR-DRG and ROM interpretation.

The successful candidate will validate clinical documentation under AHIMA/ACDIS guidelines, hold an inpatient CDI background, and aim for CCDS/CDIP certification within 12 months.

Qualifications

• 1+ year inpatient CDI experience required; ideally 2+ years.
• Strong understanding of MS-DRG, APR-DRG and ICD-10-CM/PCS.
• Strong clinical background, such as an RN/BSN or foreign-trained physician.
• Experience with EHR and encoder systems required.
• Must have or obtain CCDS or CDIP certification within 1 year of hire.

Responsibilities

• Improve quality, completeness and accuracy of clinical documentation.
• Work with providers to clarify missing, conflicting, or unclear diagnoses.
• Review and support accurate assignment of MS-DRG, APR-DRG, SOI and ROM.
• Identify relevant clinical indicators including HACs and PSIs.
• Clinical validation and compliant querying under AHIMA/ACDIS guidelines.

Skills

Inpatient CDI experience

MS-DRG knowledge

APR-DRG knowledge

ICD-10-CM/PCS knowledge

EHR experience

Encoder systems experience

RN/BSN background

CCDS/CDIP certification within 1 year

Education

RN/BSN

Foreign-trained physician

Tools

EHR systems

Medical encoder software

Job description

Community hospital part of a system looking to bring on a CDI Specialist!

• Reports to the Corporate Director of Health Information Management
• Responsible for improving the quality, completeness and accuracy of clinical documentation
• Works concurrently with providers and the healthcare team to ensure documentation accurately reflects the patient’s clinical condition and level of service
• Uses compliant provider queries to clarify missing, conflicting, unclear or clinically unsupported diagnoses
• Reviews and supports accurate assignment of MS-DRG, APR-DRG, Severity of Illness (SOI) and Risk of Mortality (ROM)
• Identifies relevant clinical indicators including HACs and PSIs
• Strong emphasis on clinical validation and compliant querying under AHIMA/ACDIS guidelines
• Individual contributor role with no direct reports

Qualifications:

• 1+ year of inpatient CDI experience required; ideally 2+ years
• Strong understanding of MS-DRG, APR-DRG and ICD-10-CM/PCS
• Strong clinical background, such as an RN/BSN or foreign-trained physician
• Experience with EHR and encoder systems required
• Must have or obtain CCDS or CDIP certification within 1 year of hire