Clinical Documentation Integrity Specialist

Emanate Health; West Covina (CA); On-site; USD 80,000 - 120,000; Full time

Job summary

Emanate Health in California seeks a Clinical Documentation Integrity Specialist (CDIS) to improve the quality, completeness, and accuracy of clinical documentation through collaboration with providers and the care team.

The CDIS will query for missing or unclear diagnoses, assign MS-DRG/APR-DRG, SOI, ROM, and identify HACs/PSIs, while upholding AHIMA/ACDIS guidelines and the CDI Code of Ethics.

Qualifications

• Bachelor's degree is required.
• Minimum of one year inpatient coding experience or CDI experience in acute care.
• Strong knowledge of MS-DRG, APR-DRG and ICD-10-CM/PCS coding guidelines.
• Experience using encoder and electronic health record (EHR) systems.
• Excellent verbal and written communication skills.
• Strong analytical thinking, problem-solving abilities, and attention to detail.
• Proficiency in Microsoft Office applications preferred.
• CDIS-related certification CCDS or CDIP within 1 year of hire/transfer.

Responsibilities

• Ensure documentation accurately reflects the patient’s clinical conditions and level of service.
• Interact with providers to address missing or unclear diagnoses via compliant queries.
• Assign MS-DRG/APR-DRG, SOI, ROM and identify relevant clinical indicators (HACs, PSIs).
• Apply AHIMA/ACDIS guidelines and the CDI Code of Ethics in daily practice.

Skills

MS-DRG knowledge

APR-DRG knowledge

ICD-10-CM/PCS coding

Encoder experience

EHR systems

Verbal and written communication

Analytical thinking

Problem-solving

Attention to detail

Education

Bachelor's degree

Tools

Microsoft Office

Job description

The Clinical Documentation Integrity Specialist (CDIS) facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team. The CDIS ensures that documentation accurately reflects the patient’s clinical conditions and level of service. The CDIS communicates with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses. The role includes appropriate assignment of MS-DRG/APR-DRG, severity of illness (SOI), risk of mortality (ROM), and identification of relevant clinical indicators (e.g., HACs, PSIs). The CDIS applies principles of clinical validation and ensures all queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics.

Job Requirements

Bachelor's degree required.

Minimum Experience Requirement:

Minimum of one (1) year of inpatient coding experience and/or experience working as a Clinical Documentation Integrity Specialist in an acute care setting. Strong knowledge of MS-DRG, APR-DRG, ICD-10-CM/PCS coding guidelines. Experience using encoder and electronic health record (EHR) systems. Excellent verbal and written communication skills. Strong analytical thinking, problem-solving abilities, and attention to detail. Proficiency in Microsoft Office applications preferred.

ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer.