Clinical Documentation Integrity Specialist: Elevate Care

Socket.dev; West Covina (CA); Remote; USD 78,000 - 112,000; Full time

Job summary

Emanate Health is seeking a Clinical Documentation Integrity Specialist (CDIS) to promote accurate documentation of diagnoses and treatments. The role involves real-time interaction with providers to address missing or unclear clinical information and ensure proper MS-DRG/APR-DRG framing.

The CDIS will ensure documentation supports the patient’s severity and risk of mortality, while following CDI ethics and AHIMA/ACDIS guidelines.

Qualifications

• Bachelor's degree preferred.
• Minimum of one year of inpatient coding experience and/or experience as a Clinical Documentation Integrity Specialist.
• 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.

Responsibilities

• Facilitate the overall quality, completeness, and accuracy of clinical documentation.
• Ensure documentation reflects patient clinical conditions and level of service.
• Query providers to address missing, unclear, or clinically unsupported diagnoses.
• Assign MS-DRG/APR-DRG, severity of illness (SOI), and risk of mortality (ROM).
• Identify relevant clinical indicators (e.g., HACs, PSIs).
• Apply AHIMA/ACDIS guidelines and the CDI Code of Ethics.

Skills

Analytical thinking

Problem-solving

Attention to detail

Verbal and written communication

Education

Bachelor's degree preferred

Tools

Encoder

Electronic Health Record (EHR) systems

Microsoft Office

Job description

Emanate Health is seeking a Clinical Documentation Integrity Specialist (CDIS) to promote accurate documentation of diagnoses and treatments. The role involves real-time interaction with providers to address missing or unclear clinical information and ensure proper MS-DRG/APR-DRG framing.

The CDIS will ensure documentation supports the patient’s severity and risk of mortality, while following CDI ethics and AHIMA/ACDIS guidelines.