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Clinical Documentation Integrity Jobs in Indiana

Reid Home Health

RN - SLR

Richmond, IN · On-site

$31 - $41.75/hr

RN - Clinical Documentation Integrity Follows the American Health Information Management Association's Ethical Standards for Clinical Documentation Professionals. The CDI Specialist works towards ...

Boca Recovery Center

Clinical Director

Bloomington, IN

$74K - $100K/yr

Monitor clinical documentation for quality, accuracy, and compliance with state and federal ... Ability to manage crisis situations and lead with integrity and compassion Preferred Qualifications

Boca Recovery Center

Clinical Director

Bloomington, IN · On-site

$74K - $100K/yr

Monitor clinical documentation for quality, accuracy, and compliance with state and federal ... Ability to manage crisis situations and lead with integrity and compassion Preferred Qualifications

Boca Recovery Center

Clinical Director

Bloomington, IN · On-site

$74K - $100K/yr

Monitor clinical documentation for quality, accuracy, and compliance with state and federal ... Ability to manage crisis situations and lead with integrity and compassion Preferred Qualifications

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All JobsClinical Documentation Integrity JobsClinical Documentation Integrity Jobs in Indiana

Clinical Documentation Integrity information

See Indiana salary details

$18

$37

$56

How much do clinical documentation integrity jobs pay per hour?

As of Aug 10, 2026, the average hourly pay for clinical documentation integrity in Indiana is $37.40, according to ZipRecruiter salary data. Most workers in this role earn between $31.78 and $42.79 per hour, depending on experience, location, and employer.

What are some typical challenges faced in a clinical documentation integrity role?

Professionals in Clinical Documentation Integrity often encounter challenges such as bridging communication gaps between clinical staff and coders, staying updated on constantly evolving healthcare regulations, and ensuring documentation accuracy under tight deadlines. The role requires balancing the needs for thorough clinical detail with the practicalities of busy healthcare environments. You may also need to educate or coach providers on best documentation practices to improve compliance and quality metrics. Successfully navigating these challenges is a rewarding way to directly impact patient care standards and organizational financial health.

What are the key skills and qualifications needed to thrive in the clinical documentation integrity position, and why are they important?

To thrive in Clinical Documentation Integrity, you need a strong background in medical coding, clinical terminology, and healthcare regulations, often supported by an RHIA, RHIT, or CCS certification. Familiarity with electronic health record (EHR) systems, coding software, and quality assurance tools is critical for day-to-day responsibilities. Attention to detail, analytical thinking, and effective communication are key soft skills for collaborating with clinicians and ensuring thorough documentation. These skills are essential for ensuring accurate patient records, compliance with regulations, and the optimization of healthcare reimbursement.

How to get an entry level clinical documentation integrity job?

To secure an entry-level clinical documentation integrity position, candidates typically need a background in healthcare, such as a medical coding, billing, or health information management certification, along with strong attention to detail and knowledge of medical terminology. Gaining experience through internships or related healthcare roles can also improve prospects, and some employers may require or prefer certification in clinical documentation improvement or coding. Familiarity with electronic health records (EHR) systems is often beneficial.

What is a clinical documentation integrity?

A Clinical Documentation Integrity (CDI) job involves reviewing medical records to ensure accurate, complete, and compliant documentation. CDI professionals work closely with physicians, coders, and healthcare teams to clarify diagnoses, procedures, and other essential details. Their role helps improve patient care, optimize reimbursements, and support regulatory compliance. Effective documentation also enhances data quality for research and reporting.

What does a clinical documentation integrity specialist do?

A clinical documentation integrity specialist reviews and improves the accuracy and completeness of patient medical records to ensure proper coding and billing. They collaborate with healthcare providers to clarify documentation, support compliance, and optimize reimbursement, often using electronic health record systems and requiring knowledge of medical terminology and coding standards.
What are popular job titles related to Clinical Documentation Integrity jobs in Indiana? For Clinical Documentation Integrity jobs in Indiana, the most frequently searched job titles are:
What job categories do people searching Clinical Documentation Integrity jobs in Indiana look for? The top searched job categories for Clinical Documentation Integrity jobs in Indiana are:
Clinical Documentation Integrity jobs near you
Infographic showing various Clinical Documentation Integrity job openings in Indiana as of July 2026, with employment types broken down into 3% As Needed, 80% Full Time, 11% Part Time, and 6% Contract. Highlights an 97% In-person, and 3% Hybrid job distribution, with an average salary of $77,783 per year, or $37.4 per hour.

RN - SLR

Reid Home Health

Richmond, IN • On-site

$31 - $41.75/hr

Other

Re-posted 4 days ago

Job description

RN - Clinical Documentation Integrity

Follows the American Health Information Management Association's Ethical Standards for Clinical Documentation Professionals. The CDI Specialist works towards optimizing reimbursement. Optimization is the process of striving to obtain the highest possible payment to which the facility is legally entitled on the basis of coded data supported by documentation in the health record. The CDI Specialist works extensively with physicians, Advanced Practice Providers, Nursing, HIM Coders, and others to ensure timely and accurate documentation.

Overview of Responsibilities

  • Concurrently and retrospectively reviews inpatient medical records to identify the most appropriate principal diagnosis and to assign a working DRG.
  • Completes the initial review within 24 hours of admission.
  • Completes concurrent reviews to ensure working DRG and all comorbid conditions are documented by the providers to the greatest specificity. Ensures documentation supports diagnoses.
  • Collaborates with the coding staff concurrently and retrospectively to ensure the chart has all the necessary documentation to support the most accurate coding.
  • Ensures the medical record reflects the patient's severity of illness and risk of mortality.
  • Sends compliant queries to providers for clarification regarding documentation.
  • Reviews one-day stay and second surgical review cases each week.
  • Provides in-person CDI training to providers one-on-one.
  • Assists in other monitoring activities, special department projects, or other needs as determined by the department director.
  • Provides ongoing CDS team learning opportunities through sharing of professional knowledge and journal articles.
  • Maintains integrity and compliance in all chart reviews and CDI documentation and queries at all times.
  • CDS will support and implement quality measures as identified by the department manager.

This list of duties and responsibilities is not intended to be all-inclusive and can be expanded to include other duties or responsibilities that management deems necessary.

Education & Experience

  • Education Required: ASN or Associate of Science in Health Information Management.
  • Education Preferred: Advanced degrees in Nursing or Health Information Management.
  • Experience Required: 2 or more years of experience working in an acute care setting or ambulatory office setting.
  • Experience Preferred: Previous experience in CDI.

Licensure & Certification

  • Licensure: Registered Nurse as applicable.
  • Certifications: RHIA, RHIT, CCS, Certified Clinical Documentation Specialist (CCDS), OR Certified Documentation Improvement Professional (CDIP), LPN, RN.

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