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Clinical Document Integrity Specialist
HCCS - Healthcare Coding & Consulting ServicesClinical Documentation Integrity Specialist at Healthcare Coding & Consulting Services. Responsible for improving clinical documentation quality within a Level I Trauma Academic Medical Center.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Documentation Integrity (CDI) with a strong focus on MS-DRGs, ICD-10-CM/PCS coding guidelines, and compliant physician query practices. Proven ability to collaborate with healthcare professionals to enhance documentation quality and support accurate coding and reimbursement.
Highest-signal resume keywords
Active Registered Nurse (RN) LicenseClinical Documentation Integrity (CDI) ExperienceMS-DRG KnowledgeICD-10-CM/PCS Coding GuidelinesElectronic Health Record (Epic) Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Clinical Documentation ReviewCoding Guidelines ApplicationDocumentation Trend AnalysisCompliant Query PracticesDocumentation Integrity Initiatives
Soft Skills
Critical ThinkingAnalytical SkillsCommunication Skills
Tools & Technologies
Electronic Health Record (EHR)Epic
Certifications & Qualifications
Registered Nurse (RN)CCSCICCDIPCCDS
Industry Keywords
Inpatient Medical RecordsSeverity of Illness (SOI)Risk of Mortality (ROM)Level I Trauma Academic Medical CenterTeaching Hospital
About the role
Key responsibilities & impact- Perform concurrent and retrospective reviews of inpatient medical records to improve the quality and accuracy of clinical documentation
- Identify opportunities to clarify documentation that supports accurate code assignment, severity of illness, risk of mortality, quality metrics, and reimbursement
- Collaborate with physicians through compliant query practices to obtain complete and accurate documentation
- Partner with inpatient coding professionals to ensure documentation supports appropriate code assignment and accurate DRG assignment
- Monitor assigned patient populations throughout hospitalization and perform follow-up documentation reviews as needed
- Apply current CMS regulations, ICD-10-CM/PCS coding guidelines, MS-DRG methodologies, and Coding Clinic guidance
- Promote provider education and documentation best practices that improve documentation integrity and patient outcomes
- Analyze documentation trends and identify opportunities for process improvement
- Participate in multidisciplinary collaboration to support documentation integrity initiatives
- Maintain productivity, quality, and compliance standards established by HCCS and our client partners.
Requirements
What you’ll need- Active Registered Nurse (RN) license required
- CCS, CIC, CDIP, and/or CCDS certification preferred, but not required
- Minimum of three (3) years of recent Clinical Documentation Integrity (CDI) experience in a Level I Trauma Academic Medical Center or Teaching Hospital
- Recent concurrent inpatient CDI experience required
- Experience reviewing complex inpatient cases within a Level I Trauma academic healthcare environment required
- Strong understanding of MS-DRGs, ICD-10-CM/PCS coding guidelines, severity of illness (SOI), risk of mortality (ROM), and compliant physician query practices
- Experience collaborating directly with physicians and interdisciplinary clinical teams
- Excellent critical thinking, analytical, and communication skills
- Experience working within an electronic health record (Epic experience preferred, if applicable)
- Must be authorized to work in the United States.
Benefits
Comp & perks- Competitive compensation
- Comprehensive benefits package
- Supportive leadership
- Opportunities for professional growth