Clinical Doc Improve Spec 1

Community Medical Centers; Fresno (CA); On-site; USD 90,000 - 110,000; Full time

Benefits offered by this job

Free CE & cert

Tuition reimbursement

Vacation from day 1

403(b) with company match

Job summary

Community Medical Centers in Fresno, CA, is seeking a CDI Specialist 1 to review patient records, ensure documentation accuracy, and support appropriate severity of illness and complexity of care. You will educate the care team on documentation guidelines and collaborate with physicians to obtain essential documentation.

The role requires nursing or medical training, with 5 years of acute-care experience; CA RN license or ECFMG certification if applicable; certifications like CCDS/CDIP are

Qualifications

• Bachelor's Degree in Nursing preferred.
• Associate's Degree in Nursing or higher, MD/DO, or foreign medical degree with USMLE steps required.
• RN license in California if nursing education; ECFMG if foreign education.

Responsibilities

• Reviews patient medical records to ensure documentation is accurate and up-to-date.
• Facilitates and obtains physician documentation for clinical conditions to support severity of illness and complexity.
• Educates the care team on documentation guidelines.

Skills

Clinical documentation

Education

Education

Bachelor's Degree in Nursing

Associate's Degree in Nursing

MD (Medical Doctor)

DO (Osteopathic Doctor)

Foreign medical degree with USMLE steps

Job description

Overview

Opportunities for you!

• Consecutively recognized as a top employer by Forbes, and in 2025 by Newsweek

• Free Continuing Education and certification

• Tuition reimbursement, education programs and scholarships

• Vacation time starts building on Day 1, and builds with your seniority

• Free money toward retirement with a 403(b) and matching contributions

Commitment to diversity and inclusion is a cornerstone of our culture at Community. All are welcome as valued members of our community.

We know that our ability to provide the highest level of care is through taking care of our incredible teams. Learn more on our Benefits page.

Responsibilities

The Clinical Documentation Improvement (CDI) Specialist 1 conducts reviews of patient medical records to ensure documentation is accurate and up-to-date. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Educates members of the patient care team regarding documentation guidelines.

Qualifications

Education

• Bachelor's Degree in Nursing preferred

One of the following is required:

• Associate's Degree or higher in Nursing

• Doctor of Medicine (MD) from an accredited medical school

• Doctor of Osteopathic Medicine (DO) from an accredited medical school

• Medical Degree from a foreign medical school with successful completion of the USMLE Step 1 and Step 2 Exams

Experience

• 5 years of clinical experience in an acute hospital setting with demonstrated expertise in Med/Surg, OB, Trauma, ICU, and/or CCU required

• Prior coding or Clinical Documentation Improvement (CDI) program experience preferred

Licenses and Certifications

• RN - Current and valid Registered Nurse license to work within the state of California (if education is in Nursing) required

• ECFMG - Educational Commission for Foreign Medical Graduates (if education is from a foreign medical school) required

One of the following is preferred:

• CCDS - Certified Clinical Documentation Specialist

• CDIP - Certified Documentation Improvement Practitioner

Disclaimers

Pay ranges listed are an estimate and subject to change. If any bonuses are noted, they are only applicable to external hires meeting criteria.