The Clinical Documentation Integrity Specialist ensures accuracy, completeness, and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. This role involves concurrent chart reviews to validate that clinical documentation accurately reflects patient severity of illness, complexity of care, and risk of mortality, facilitating appropriate coding. The specialist uses advanced knowledge of disease processes and medications, applying critical thinking to identify documentation gaps. They collaborate extensively with providers, coding, quality, and case management teams to facilitate documentation modifications. Acting as an educator and resource, they promote improved documentation practices.

Responsibilities include analyzing medical records for incomplete or inaccurate documentation, periodically analyzing coding data to identify variations, conducting concurrent chart reviews, working closely with healthcare professionals to clarify documentation, supporting medical coders to ensure compliance with coding guidelines, conducting training sessions on documentation and coding requirements, utilizing data analytics to identify improvement areas, monitoring DRG assignments and performance indicators, understanding quality measure initiatives such as Value Based Purchasing, conducting documentation quality audits, participating in quality improvement initiatives, and maintaining compliance with HIPAA and information security policies.

Qualifications required are a minimum of 3 years experience in inpatient clinical documentation improvement, 5 years nursing experience in adult acute care (med/surg, critical care, emergency, or PACU), RN license, and CCDS and/or CDIP certification. Coding credentials (CCS, CPC, CCS-P) and Registered Nurse license are highly preferred. Must possess knowledge of ICD-10 coding guidelines, DRG reimbursement, strong analytical and communication skills, self-motivation, and proficiency in computer applications including Microsoft Office and CDI workflow tools.

Working conditions involve physical demands such as sitting, manual tasks, light lifting, and mental demands including collaboration and stress management in a well-lighted, ventilated office setting with minimal exposure risks.