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

cvhp; West Covina (CA); Presencial; USD 104.000 - 160.000; Jornada completa

Descripción de la vacante

Emanate Health is seeking a Clinical Documentation Integrity Specialist to ensure the accuracy and completeness of patient documentation. You will collaborate with providers to resolve unclear diagnoses and assign MS-DRG/APR-DRG, SOI, and ROM.

The role requires a Bachelor's degree, inpatient coding experience, and CCDS or CDIP certification within 1 year, with proficiency in EHR systems and Microsoft Office. This is a full-time position in a healthcare setting.

Formación

• Bachelor's degree required.
• Minimum of one (1) year of inpatient coding experience and/or experience as a Clinical Documentation Integrity Specialist in an acute care setting.
• 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 CCDS or AHIMA CDIP required within 1 year of hire/transfer.

Responsabilidades

• Facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and the healthcare team.
• Ensures documentation reflects patient conditions and level of service, including MS-DRG/APR-DRG, SOI, ROM, and clinical indicators.
• Uses AHIMA/ACDIS guidelines and the CDI Code of Ethics to guide queries and validations.

Conocimientos

Analytical thinking

Problem-solving

Attention to detail

Verbal & written communication

Educación

Bachelor's degree

Herramientas

Encoder

EHR systems

Microsoft Office

Descripción del empleo

Everyone 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 Summary

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

Minimum 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