Clinical Documentation Integrity Specialist

Emanate Health; West Covina (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Emanate Health in West Covina, CA seeks a Clinical Documentation Integrity Specialist (CDIS) to enhance documentation quality and accuracy. The role involves collaborating with providers to resolve missing or unclear diagnoses and ensuring proper DRG assignment and clinical indicators.

The ideal candidate will have inpatient coding experience, strong knowledge of DRG guidelines, and CCDS/CDIP certification within a year. Proficiency with encoder, EHR, and Microsoft Office is preferred.

Qualifications

• Bachelor's degree required.
• Minimum 1 year inpatient coding experience in an acute care setting.
• Strong MS-DRG, APR-DRG, ICD-10-CM/PCS knowledge.
• Experience using encoder and EHR systems.
• Excellent verbal and written communication skills.
• Strong analytical thinking and attention to detail.
• Proficiency in Microsoft Office preferred.
• ACDIS CCDS or AHIMA CDIP required within 1 year of hire/transfer.

Responsibilities

• Facilitate quality and accuracy of clinical documentation through interaction with providers.
• Query providers to address missing, unclear, or conflicting diagnoses.
• Assign MS-DRG/APR-DRG, SOI, ROM and identify relevant clinical indicators.
• Ensure queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics.

Skills

Inpatient coding

MS-DRG/APR-DRG

ICD-10-CM/PCS

EHR systems

Communication

Attention to detail

Education

Bachelor's degree

Tools

Encoder

Microsoft Office

EHR software

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.