Clinical Document Integrity Specialist, Full-Time

About the Role

Enhance the quality and completeness of inpatient clinical documentation through concurrent review, collaboration, and technology-driven insights.

Responsibilities

• Conduct concurrent review of inpatient records to ensure accurate code assignment, severity of illness, and risk of mortality capture.
• Facilitate documentation improvements by collaborating with physicians, nursing, and coding staff to reflect services provided and patient conditions accurately.
• Utilize integrated workflows, technology-supported review worklists, and data insights to identify documentation gaps and ensure timely, compliant clarifications.
• Support the transition to new electronic health record systems and collaborate on DRG encoder integration.
• Improve documentation accuracy, support compliance, educate care teams, and contribute to quality reporting and appropriate reimbursement across various payers.

Requirements

• MD/DO degree (international medical graduates considered).
• At least 3 years of inpatient medical, surgical, or critical care experience.
• Knowledge of coding regulations, DRG assignment, documentation integrity, utilization, and quality.
• Experience with electronic health records (EHRs), analytics, AI tools, and documentation guidelines is preferred.
• Basic computer skills and ability to collaborate with coding professionals.