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Clinical Documentation Integrity Specialist – FT
Vee TechnologiesCDI Specialist performing concurrent inpatient documentation reviews to enhance documentation accuracy for healthcare organizations. Collaborating with teams to support coding accuracy and compliance standards.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical documentation improvement (CDI) with a focus on ICD-10-CM/PCS coding accuracy, clinical validation, and compliant physician queries. Proven ability to collaborate with healthcare teams to enhance documentation quality and ensure compliance with CMS regulations.
Highest-signal resume keywords
Active RN LicenseCCDS CertificationCDI Experience in Acute Care HospitalICD-10-CM/PCS KnowledgeExperience with CDI Platforms
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ValidationICD-10-CM/PCS CodingMS-DRG/APR-DRG AssignmentCompliant Physician QueriesDocumentation Review
Soft Skills
CollaborationEducation and Training
Tools & Technologies
EpicCernerSolventum 360IodineSmarterDx
Certifications & Qualifications
CCDSCDIP
Industry Keywords
Clinical Documentation ImprovementCMS RegulationsQuality MetricsPOA IndicatorsCC/MCC Capture
About the role
Key responsibilities & impact- Perform concurrent inpatient documentation reviews to identify opportunities for improved documentation specificity, clinical validation, and coding accuracy.
- Conduct compliant physician queries following AHIMA/ACDIS guidance to clarify conflicting, incomplete, or ambiguous documentation.
- Support accurate ICD-10-CM/PCS coding, MS-DRG/APR-DRG assignment, POA indicators, CC/MCC capture, SOI/ROM, PSIs, HACs, and quality metrics.
- Perform clinical validation reviews for high-impact diagnoses including sepsis, acute respiratory failure, AKI, encephalopathy, malnutrition, and other complex conditions.
- Collaborate with coding, CDI, quality, and physician teams to improve documentation quality and reduce denials.
- Provide physician and CDI education based on documentation trends and audit findings.
- Monitor productivity, quality, and compliance standards while participating in internal audits and continuous improvement initiatives.
- Maintain current knowledge of CMS regulations, ICD-10-CM/PCS, Coding Clinic, AHIMA, and ACDIS guidance.
Requirements
What you’ll need- Active RN license or graduate of an accredited medical program (MD, DO, MBBS, NP, PA, or equivalent clinical background)
- CCDS or CDIP certification required
- Minimum 5 years of concurrent inpatient CDI experience in an acute care hospital
- Strong knowledge of MS and APR-DRG reimbursement, ICD-10-CM/PCS, clinical validation, and compliant query practices
- Experience with Epic, Cerner, Solventum 360, Iodine, SmarterDx, or similar CDI platforms
Benefits
Comp & perks- medical/dental/vision benefits first of the month following date of hire
- 401k benefits plus paid holidays and PTO/personal time