Clinical Documentation Integrity Specialist, Per Diem
CVHP Project & Development Management
part-time
Posted on:
Location Type: Remote
Location: California • United States
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Salary
💰 $69 per hour
Job Level
About the role
- Facilitates the overall quality, completeness, and accuracy of clinical documentation through concurrent interaction with providers and other members of the healthcare team
- Ensures documentation accurately reflects the patient’s clinical conditions and level of service
- Communicates with providers through discussion and/or compliant queries to address missing, unclear, conflicting, or clinically unsupported diagnoses
- 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)
- Applies principles of clinical validation and ensures all queries comply with AHIMA/ACDIS guidelines and the CDI Code of Ethics
Requirements
- Medical degree or Bachelor of Science in Nursing (BSN) preferred
- 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
- ACDIS Certified Clinical Documentation Specialist (CCDS) or AHIMA Certified Documentation Integrity Practitioner (CDIP) required within 1 year of hire/transfer
Benefits
- Health insurance
- Retirement plans
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
inpatient codingclinical documentation integrityMS-DRGAPR-DRGICD-10-CMICD-10-PCSclinical validationclinical indicatorsseverity of illnessrisk of mortality
Soft Skills
communication skillsanalytical thinkingproblem-solvingattention to detail
Certifications
ACDIS Certified Clinical Documentation Specialist (CCDS)AHIMA Certified Documentation Integrity Practitioner (CDIP)