The Clinical Documentation Integrity Specialist ensures the accuracy, completeness, and consistency of inpatient clinical documentation to support coding and high-quality healthcare data reporting. Responsibilities include concurrent chart reviews to validate that documentation accurately describes patient severity of illness, complexity of care, and risk of mortality for appropriate coding. They analyze medical records and coding data to identify documentation gaps and variations, collaborate extensively with providers, coding, quality, and case management teams to facilitate documentation modifications, and provide education and support for proper documentation and compliance.

This role works closely with physicians, nurses, and other healthcare professionals to clarify and improve clinical documentation, supports medical coders, communicates coding-related issues, conducts training on documentation practices and coding guidelines, utilizes data analytics for performance improvements, and participates in quality improvement initiatives. The specialist ensures documentation aligns with regulatory requirements, coding standards, and healthcare policies while following HIPAA and information security guidelines.

Qualifications include a minimum of 3 years experience in inpatient clinical documentation improvement, 5 years of nursing experience in adult acute care (med/surg, critical care, emergency, or PACU), required RN license, CCDS and/or CDIP certification, and coding credentials like CCS, CPC, or CCS-P preferred. Strong analytical, communication, and computer skills are necessary.