Clinical Documentation Integrity Specialist

Welcome to Montage Health’s application process!

Job Description:

The Clinical Documentation Integrity (CDI) Specialist - Physician Education & DRG Integrity is an in-house, concurrent documentation role responsible for working directly with physicians, advanced practice providers, HIM coding, quality, case management, and revenue cycle leadership to improve the accuracy, completeness, and clinical integrity of inpatient documentation. This position works elbow-to-elbow with physicians and care teams to help identify the working DRG on day one of admission, improve documentation of the principal diagnosis and clinically relevant secondary diagnoses, and reduce the need for retrospective queries through real-time collaboration, education, and trend-based intervention.

The role is designed to support the development of a fully internal inpatient CDI program and aligns with Vizient/Kaufman Hall recommendations related to program structure, workflows, and governance.

Experience Required

• Minimum 3-5 years of acute care hospital experience in Clinical Documentation Integrity (CDI), inpatient coding, Health Information Management (HIM), case management, utilization management, quality improvement, or related clinical operations.

• Minimum 3 years of concurrent inpatient CDI experience performing documentation reviews, provider education, and compliant documentation clarification activities.

• Minimum 3 years of inpatient coding experience with demonstrated knowledge of ICD-10-CM/PCS coding, MS-DRG assignment, principal diagnosis selection, CC/MCC capture, and coding compliance requirements.

• Demonstrated experience collaborating directly with physicians, advanced practice providers, coding professionals, and interdisciplinary teams.

• Strong working knowledge of:

• MS-DRG reimbursement methodology

• ICD-10-CM/PCS coding principles

• Principal and secondary diagnosis assignment

• Severity of Illness (SOI) and Risk of Mortality (ROM)

• Clinical indicators and clinical validation

• Query compliance standards

• Documentation requirements impacting quality, reimbursement, denials, and regulatory reporting

Preferred

• Physician-facing CDI or Physician Documentation Liaison experience.

• Experience providing physician education related to clinical documentation, coding, quality metrics, and DRG optimization.

• Experience with CDI analytics, reporting, and performance improvement initiatives.

• Experience supporting CDI program implementation, insourcing, or optimization efforts.

• Experience utilizing Epic, CDI technology platforms, and coding workflow tools.

Education, Licensure & Certifications

Required:

• California RN license for candidates qualifying through the RN pathway.
  • RN Licensure Clarification: This position performs CDI/HIM functions and does not include direct patient care or the practice of nursing. Candidates qualifying through the RN pathway may hold an active, unrestricted RN license from any U.S. state.

• CCS or CCS-P

Preferred:

• CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner)
• Candidates processing both CDI and Coding credentials
• Additional AHIMA, ACDIS, or HFMA certifications relevant to CDI, coding, compliance, quality, or healthcare revenue cycle

Ideal Candidate Profile

• Strong background in both inpatient coding and clinical documentation integrity.
• Able to translate coding, quality, clinical, and reimbursement concepts into meaningful physician education.
• Trusted physician partner capable of improving documentation quality while maintaining compliance and clinical integrity.

Equal Opportunity Employer

#LI-RL1

Assigned Work Hours:

Full time, day shift

Position Type:

Pay Range (based on years of applicable experience):

to

The hours employees work determine when a shift differential is paid.