CDI Specialist: Elevate Clinical Documentation

NOR Healthcare Systems; Tustin (CA); On-site; USD 87,000 - 120,000; Full time

Job summary

NOR Healthcare Systems is seeking a CDI Specialist Level I in California to conduct concurrent and retrospective reviews of inpatient records, ensuring documentation supports medical necessity, quality of care, and compliant reimbursement.

You will collaborate with physicians, coders, and staff to resolve ambiguity, perform audits, and educate teams on documentation guidelines while maintaining HIPAA compliance and patient confidentiality.

Qualifications

• Must hold CA license as Medical Graduate, PA or RN.
• Ability to multitask and maintain workload pace.
• Excellent written and verbal communication in English.
• Able to communicate clearly with physicians.
• Computer literacy and proficiency.
• Hospital Fire and Life Safety Card (LA Employees only).

Responsibilities

• Reviews inpatient records for identified payor populations and ensures complete, accurate documentation.
• Resolves inconsistent documentation via physician query and follows up before discharge.
• Audits records to improve completeness and accuracy of medical documentation.
• Maintains HIPAA confidentiality per policy and law.
• Reviews claims with medical necessity denials and works to reduce denials.
• Participates in case management meetings; educates staff on documentation guidelines.

Skills

Multitask ability

Customer service skills

Written and verbal communication

Communication with physicians

Computer literacy

Education

Medical Graduate, Physician Assistant or Registered Nurse (Current CA License)

Job description

NOR Healthcare Systems is seeking a CDI Specialist Level I in California to conduct concurrent and retrospective reviews of inpatient records, ensuring documentation supports medical necessity, quality of care, and compliant reimbursement.

You will collaborate with physicians, coders, and staff to resolve ambiguity, perform audits, and educate teams on documentation guidelines while maintaining HIPAA compliance and patient confidentiality.