Clinical Documentation Integrity Specialist - Per Diem - Remote - Days - 8hr

Emanate Health; West Covina (CA); Remote; USD 62,000 - 76,000; Full time

Job summary

Emanate Health seeks a Clinical Documentation Integrity Specialist (CDIS) to improve the completeness and accuracy of clinical documentation. The CDIS will interact with providers to address missing or unclear diagnoses and ensure proper assignment of MS-DRG/APR-DRG, SOI, and ROM.

The role requires knowledge of MS-DRG/APR-DRG, ICD-10-CM/PCS coding, and experience with encoder and EHR systems, along with strong communication and analytical skills.

Qualifications

• Bachelor’s degree preferred.
• 1 year inpatient coding experience and/or CDI in acute care.
• Strong knowledge of MS-DRG, APR-DRG, ICD-10-CM/PCS guidelines.
• Experience with encoder and EHR systems.
• Excellent verbal and written communication; detail-oriented.

Responsibilities

• Ensure documentation accurately reflects patient conditions and level of service.
• Query providers to address missing or unclear diagnoses per AHIMA/ACDIS guidelines.
• Assign MS-DRG/APR-DRG, SOI, ROM, and identify indicators.
• Collaborate with care team to improve documentation quality.

Skills

MS-DRG knowledge

APR-DRG knowledge

ICD-10-CM/PCS coding

EHR systems proficiency

Encoder software

Analytical thinking

Communication skills

Microsoft Office

Inpatient coding experience

Education

Bachelor's degree

Tools

Encoder software

Job description

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 preferred.

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: $69.00 - $69.00