Clinical Document Integrity Specialist, Full-Time

Role

Clinical Document Integrity Specialist responsible for enhancing the quality and completeness of inpatient clinical documentation.

Conducts concurrent review of inpatient records to ensure accurate code assignment, severity of illness, and risk of mortality capture. Facilitates documentation improvements through collaboration with physicians, nursing, and coding staff to reflect services provided and patient conditions accurately. Utilizes integrated workflows, technology-supported review worklists, and data insights to identify documentation gaps and ensure timely, compliant clarifications. Supports the transition to new electronic health record systems and collaborates on DRG encoder integration.

Requires MD/DO degrees, with international medical graduates considered. At least 3 years of inpatient medical/surgical/critical care experience. Knowledge of coding regulations, DRG assignment, documentation integrity, utilization, and quality. Experience with EHRs, analytics, AI tools, and documentation guidelines is preferred. Basic computer skills and collaboration with coding professionals are essential.

Improve documentation accuracy, support compliance, educate care teams, and contribute to quality reporting and appropriate reimbursement across various payers.