Clinical Document Improvement Specialist II - Sharp Tri-City Medical Center

150 Sharp Tri-City Medical Center; Vista (CA); On-site; USD 79,000 - 103,000; Full time

Job summary

150 Sharp Tri-City Medical Center seeks a Clinical Documentation Improvement Specialist (CDI) to perform concurrent review of medical records and issue physician inquiries, ensuring accurate documentation and DRG assignment. The role collaborates with case management, coding staff, and physicians to close documentation gaps and improve reimbursement.

Requires RN with California license, 5+ years RN experience, 2+ years CDI experience, and current CDI certification from ACDIS.

Qualifications

• Bachelor's Degree in Nursing required.
• California RN license required.
• 5+ years RN experience required.
• 2+ years CDI experience required.
• Current CDI certification from ACDIS required.

Responsibilities

• Performs concurrent review of medical records and issues physician inquiries.
• Collaborates with case management, coding staff and medical staff to improve documentation quality.
• Analyzes documentation to ensure accurate DRG assignment and case mix data.
• Queries providers to clarify incomplete documentation ethically and compliantly.
• Facilitates accurate reimbursement by addressing insurance queries and ensuring proper compensation.

Skills

Communication

Teamwork

Analytical

Leadership

Education

Bachelor's Degree in Nursing

Tools

Microsoft Word

Job description

Hours: Shift Start Time: 7 AM Shift End Time: 4:30 PM AWS Hours Requirement: 8/40 - 8 Hour Shift Additional Shift Information: Weekend Requirements: Every Other On-Call Required: No Hourly Pay Range (Minimum - Midpoint - Maximum): $57.000 - $66.110 - $75.210 This position is covered by a Collective Bargaining Agreement (CBA) with CNA.

What You Will Do

The Clinical Documentation Improvement Specialist (CDI) performs concurrent review of medical records. Issues concurrent physician inquiries, and interacts with the medical staff and other healthcare staff in an effort to assure complete and accurate documentation of the patient’s clinical picture and the treatment provided. The CDI acts as a liaison between case management, coding professionals and the medical staff. The CDI is responsible for improving overall quality and completeness of clinical documentation.

Required Qualifications

• Bachelor's Degree in Nursing
• 5 Years Registered Nurse experience.
• 2 Years Registered Nurse in Clinical Documentation Improvement experience.
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Preferred Qualifications

• Experience with referral management system.
• Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA) -PREFERRED
• Registered Health Information Technician (RHIT) - The American Health Information Management Association (AHIMA) -PREFERRED
• Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) -PREFERRED
• Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED
• Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED
• Current CDI certification through the Association of Clinical Documentation Improvement Specialists (ACDIS). - REQUIRED

Essential Functions

Maintains a safe, clean working environment, including unit based safety and infection control requirements.

Clinical Documentation Improvement: Review medical records for completeness and accuracy, identifying any missing or unclear information regarding diagnoses, treatments, and care plans.

Analyze documentation to clarify and validate diagnoses, ensuring accurate Diagnostic Related Group (DRG) assignment, severity of illness, risk of mortality, and case mix data.

Collaborate with physicians, nurses, coders, and other healthcare staff to address documentation gaps and improve overall record quality.

Query providers to clarify inconsistent or incomplete documentation in an ethical, compliant manner.

Facilitate accurate reimbursement by tracking insurance queries and ensuring providers receive appropriate compensation for their services.

Develop CDI policies and procedures around query processes, education, training, and performance measurements.

Report and analyze data for quality improvement purposes, preparing feedback for team members and leadership.

Completes concurrent review of assigned population; achieving a high accuracy rate.

Safety and Compliance: Maintain a safe, clean working environment, adhering to infection control and hospital policies.

Monitor and audit records to ensure regulatory compliance (including HIPAA), prevent fraud, and avoid unnecessary insurance denials.

Comply with regulatory standards (e.g., The Joint Commission, OSHA).

Identify and report safety concerns proactively.

Professional Development and Leadership: Provide education to clinical staff on proper documentation practices and coding criteria, including ongoing training and development.

Participate in program meetings, staff education, development activities, and in-service opportunities.

Analyze trends and data to recommend process improvements for accurate clinical documentation.

Develop and implement formal and informal education plans for physicians, nurses and clinical staff to improve accuracy in clinical documentation.

Provide preceptorship and mentorship to New Graduate Nurses, New Hires, and students, supporting their professional development.

Serve as a resource for best practices within Clinical Documentation & Case Management/Utilization Review.

Knowledge, Skills, and Abilities

• Proficient computer skills, including Word.
• Knowledge and understanding of various payer types.
• Knowledge of ICD-10-CM coding conventions, risk adjustment models, and Hierarchical Condition Category Coding (HCC).
• Expert knowledge of clinical care and coding guidelines.
• Detail-oriented approach to reviewing and improving medical documentation.
• Strong prioritization skills.
• Self-motivated, independent thinker.
• Strong communication, teamwork, analytical, and leadership skills.
• Ability to analyze, educate, and communicate effectively with diverse clinical teams.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class.

Sharp HealthCare is a not-for-profit health care system based in San Diego, California, with four acute care hospitals, three specialty hospitals, three medical groups and a health plan.

We provide medical services in virtually all fields of medicine, including primary care, heart care, cancer, orthopedics, women’s health, rehabilitation, robotic surgery and bariatric surgery.

Sharp sets the community standard for exceptional care. Sharp Grossmont Hospital and Sharp Memorial Hospital have received prestigious Magnet recognition by the American Nurses Credentialing Center for excellence in nursing practices and quality patient care.

At the heart of our organization are more than 18,000 affiliated physicians, nurses, staff and volunteers who are on a journey to make health care better for our patients and their families. It’s what we call The Sharp Experience – treating each person with dignity, compassion and respect, and using our clinical excellence and advanced technology to deliver the highest-quality patient care. We are dedicated to transforming the health care experience by making Sharp the best place to work, the best place to practice medicine and the best place to receive care in San Diego.