Clinical Documentation Integrity Specialist - Full Time On-Site - Days - 8hr QVH

Emanate Health; West Covina (CA); On-site; USD 69,000 - 105,000; Full time

Job summary

Emanate Health is seeking a Clinical Documentation Integrity Specialist (CDIS) to ensure accurate, complete clinical documentation for inpatient encounters. You will interact with providers to resolve missing or unclear diagnoses and assign MS-DRG/APR-DRG, SOI, ROM, and relevant indicators, following AHIMA/ACDIS guidelines.

Ideal candidates have at least one year of inpatient coding or CDI experience, a Bachelor's degree, and CCDS or CDIP certification within one year.

Qualifications

• Minimum of one year inpatient coding experience or CDI specialist experience.
• Strong knowledge of MS-DRG/APR-DRG and ICD-10-CM/PCS guidelines.
• Experience using encoder and EHR systems.
• Excellent verbal and written communication skills.
• Attention to detail and analytical problem-solving abilities.

Responsibilities

• Facilitate quality and accuracy of clinical documentation.
• Query physicians to resolve missing or unclear diagnoses.
• Assign MS-DRG/APR-DRG, SOI, ROM, and relevant indicators.
• Ensure CDI practices align with AHIMA/ACDIS guidelines.

Skills

MS-DRG guidelines

APR-DRG guidelines

ICD-10-CM/PCS

Analytical thinking

Problem-solving

Attention to detail

Verbal and written communication

Education

Bachelor's degree

ACDIS CCDS or CDIP within 1 year

Tools

EHR systems

Encoder

Job description

Current Emanate Health Employees - Please log into your Workday account to applyEveryone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals.On Glassdoor's list of \"Best Places to Work\" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country.Job SummaryThe 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 RequirementsMinimum Education Requirement: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.Minimum License Requirement:ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer.Delivering world-class health care one patient at a time.Pay Range:$49.55 - $76.80