Senior Clinical Documentation Integrity Specialist

About the role

The Senior Clinical Documentation Integrity Specialist ensures accurate, complete, and compliant clinical documentation that appropriately reflects severity of illness, risk of mortality, and supports correct reimbursement. This role partners closely with providers, coding teams, and practice participants to drive documentation quality, regulatory compliance, and value-based care initiatives.

Responsibilities

• Develops and implements standard processes, job aids, and error prevention tools to strengthen clinical documentation integrity across participating practices.
• Educates providers and office staff on best-practice clinical documentation standards to ensure accuracy, completeness, and compliance.
• Conducts prospective and retrospective reviews and prepares analyses and reports to identify trends, gaps, and improvement opportunities.
• Provides guidance and consultation to internal practice staff to improve coding proficiency and documentation accuracy.
• Collaborates with population health and practice teams to support quality programs, value-based initiatives, and standardized data abstraction processes.
• Advises practice staff on compliance with applicable federal, state, and local regulations related to Medicare coding and documentation guidelines.

Requirements

• Bachelor’s degree in Nursing or a related field (4 years of related experience can be used in lieu of degree)
• Minimum of 5 years of experience in Clinical Documentation Integrity (CDI) or coding
• At least 3 years of experience supporting healthcare value-based programs, including Medicare Risk (experience may run concurrently)
• A certification, such as CPC, CRC, CCS-P, CCS-H, RHIT, CCDS, or CDIP, is required or must be obtained within 12 months of hire.
• Advanced knowledge of ICD-10 coding guidelines and clinical documentation standards
• Strong understanding of CMS quality programs, HCCs, value-based care models, and EHR systems
• Excellent written, verbal, interpersonal, and presentation skills
• Advanced proficiency in Microsoft Office applications (Excel, Word, PowerPoint, Outlook)
• Strong critical thinking, problem-solving, and time-management skills

Preferred Qualifications

• Master’s degree in Nursing, Advanced Practice Registered Nurse (APRN), or Information Management Professional (MIM)
• Advanced knowledge of preventive health standards and clinical standards of care
• Experience collaborating with population health teams and multi-disciplinary clinical stakeholders

Physical Demands

Perform other job-related duties as assigned, within your scope of responsibilities. Job duties are performed in a normal and clean office environment with normal noise levels. The physical demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions.