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Clinical Documentation Integrity Specialist Jobs

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Clinical Documentation Specialist

Manhattan, NY · Remote

$38.25 - $51.50/hr

Inpatient Clinical Documentation Integrity Specialist (ICDIS) - Remote Location: 100% Remote (Candidates can work from anywhere within the U.S.) Schedule: Sunday - Thursday Hours: 40 hours/week ...

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How much do clinical documentation integrity specialist jobs pay per hour?

As of May 28, 2026, the average hourly pay for clinical documentation integrity specialist in the United States is $39.30, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $44.95 per hour, depending on experience, location, and employer.

What are the key skills and qualifications needed to thrive as a Clinical Documentation Integrity Specialist, and why are they important?

To thrive as a Clinical Documentation Integrity Specialist, you need a deep understanding of medical terminology, clinical processes, and coding standards, often supported by a background in nursing, HIM, or related healthcare fields. Familiarity with electronic health record (EHR) systems, ICD-10 and DRG coding, and certifications such as CCDS or CDIP are typically required. Exceptional communication, analytical thinking, and attention to detail help you collaborate effectively with providers and ensure accurate documentation. These skills are crucial for improving the quality of patient records, supporting accurate reimbursement, and ensuring regulatory compliance.

How does a Clinical Documentation Integrity Specialist typically collaborate with physicians and other healthcare staff?

Clinical Documentation Integrity Specialists work closely with physicians, nurses, and coding professionals to ensure that patient records accurately reflect the care provided. They often conduct concurrent chart reviews, provide education to clinical staff on documentation best practices, and clarify information through queries. Collaboration is ongoing and requires strong communication skills to bridge clinical care and coding requirements. Building positive relationships with healthcare providers is key to fostering cooperation and improving documentation quality.

What are Clinical Documentation Integrity Specialists?

Clinical Documentation Integrity Specialists (CDIS) are healthcare professionals who ensure that medical records accurately reflect the care provided to patients. They review clinical documentation for completeness, accuracy, and compliance with regulatory standards. By working closely with physicians, nurses, and coding staff, CDIS help to clarify ambiguous or incomplete information, which improves patient care, supports appropriate reimbursement, and reduces the risk of legal or financial issues. Their role is vital in ensuring that the health record tells the complete story of the patient encounter.

Is CCDs certification worth it?

For a Clinical Documentation Integrity Specialist, obtaining a CCDs (Certified Clinical Documentation Specialist) certification can enhance credibility, demonstrate expertise, and potentially improve job prospects and salary. It is recognized in the industry as a valuable credential for professionals involved in clinical documentation improvement and coding accuracy.

What is the difference between Clinical Documentation Integrity Specialist vs Medical Coder?

AspectClinical Documentation Integrity SpecialistMedical Coder
CertificationsCDIS, RHIT, RHIACCA, CCS, CPC
Work EnvironmentHospitals, health systems, outpatient clinicsHospitals, physician offices, billing companies
Primary FocusEnsuring accurate clinical documentation for proper reimbursement and quality reportingTranslating clinical notes into standardized codes for billing

While both roles involve healthcare documentation, Clinical Documentation Integrity Specialists focus on improving clinical records for quality and reimbursement, whereas Medical Coders assign codes based on clinical documentation for billing purposes. Understanding these differences helps healthcare organizations optimize documentation and coding processes.

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Clinical Documentation Integrity Specialist jobs near you
Infographic showing various Clinical Documentation Integrity Specialist job openings in the United States as of May 2026, with employment types broken down into 82% Full Time, 17% Part Time, and 1% Contract. Highlights an 91% Physical, 3% Hybrid, and 6% Remote job distribution, with an average salary of $81,742 per year, or $39.3 per hour.
Clinical Documentation Integrity Specialist- Remote

Clinical Documentation Integrity Specialist- Remote

Med-Metrix

Parsippany, NJ • On-site, Remote

$35 - $47/hr

Full-time

Posted 11 days ago

Med-Metrix rating

7.3

Company rating: 7.3 out of 10

Based on 17 frontline employees who took The Breakroom Quiz

185th of 424 rated business services

Job description

Job Purpose
The Clinical Documentation Integrity Specialist focuses on the accuracy, completeness and consistency of inpatient clinical documentation to support coding and reporting of high-quality healthcare data. The Clinical Documentation Integrity Specialist performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient's severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding. The Clinical Documentation Integrity Specialist utilizes advanced knowledge of disease processes, medications, and has critical thinking to analyze current documentation to identify gaps in clinical documentation. The Clinical Documentation Integrity Specialist facilitates appropriate modifications to documentation through extensive interactions and collaborations with providers, coding, quality, and case management teams. This team member serves as an effective change agent as a resource and educator for providers and interdisciplinary care teams.
Duties and Responsibilities
  • Analyzes medical records to identify incomplete or inaccurate documentation related to diagnoses, treatments, and procedures
  • Periodically analyzes coding data to identify documentation variations and determine the cause and appropriateness of such variation; presents such findings to the management
  • Performs concurrent chart reviews to validate that the clinical documentation in the medical record appropriately describes the patient's severity of illness, complexity of care, and risk of mortality to facilitate appropriate coding
  • Works closely with physicians, nurses, and other healthcare professionals to clarify and obtain additional information needed for accurate documentation
  • Facilitates modification to clinical documentation supporting the clinical picture/level of severity rendered to all patients at the Hospital for DRG based payers through concurrent interactions with physicians and other members of the health care team
  • Collaborates with healthcare providers, physicians, nurses, and other stakeholders to clarify and improve documentation
  • Provides support to medical coders by ensuring documentation supports the assigned codes and compliance with coding guidelines
  • Communicates effectively with coding teams to address coding-related issues and promote accurate code assignment
  • Conducts training sessions for healthcare staff on proper documentation practices, coding guidelines, and compliance requirements, as requested by CDI manager
  • Utilizes data analytics to identify trends, patterns, and areas for improvement in documentation accuracy and completeness
  • Monitors daily DRG assignment, DRG reports and tracking areas for performance improvement to appropriately reflect optimal severity at admission and through the stay
  • Demonstrates an understanding of current Quality Measure Initiatives including Value Based Purchasing, Pay for Performance, and Readmission criteria
  • Ensuring documentation aligns with regulatory requirements, coding standards, and healthcare policies
  • Conducts regular audits to assess the quality of clinical documentation and identifying areas for improvement
  • Participates in quality improvement initiatives related to clinical documentation and coding accuracy
  • Use, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
  • Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties
  • Understand and comply with Information Security and HIPAA policies and procedures at all times

Qualifications
  • Minimum of 3 years of experience in inpatient clinical documentation improvement role required
  • Minimum of 5 years of nursing experience in adult acute care experience in med/surg, critical care, emergency, or PACU required
  • Certification minimum requirement - RN, CCDS and/or CDIP
  • Current state Registered Nursing license required.
  • Coding credential highly preferred (CCS, CPC, CCS-P)
  • Current state Registered Nurse license highly preferred
  • Clinic Fundamental knowledge of ICD-10 Official Coding Guidelines and DRG Reimbursement Systems
  • Demonstrated skills in analytical thinking, problem solving
  • Excellent communication and people skills
  • Self-motivated and able to work independently without close supervision
  • Proficient in the use of computers including Microsoft Office (Word, Excel, PowerPoint, etc.), Outlook, and other applications necessary to perform the CDS role such as an encoder or CDI workflow and reporting tool

Working Conditions
  • Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear. Perform light lifting (up to 15 pounds)
  • Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress
  • Work Environment: Works in a well-lighted/ventilated office setting. Subject to frequent interruptions. Minimal occupational exposure to infectious diseases, blood borne pathogens, hazardous chemicals, noxious odors, latex, or musculoskeletal injuries. Operate Office machines properly and in accordance with Hospital safety standards. Ability to work in accordance with Hospital Safety Standards

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

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