Clinical Documentation Improvement Specialist

County of Riverside; California; Vor Ort; USD 85.000 - 110.000; Vollzeit

Zusammenfassung

Riverside University Health System – Medical Center is seeking an Inpatient CDI Specialist for the Health Information Management division. This role focuses on concurrent reviews to ensure documentation reflects services and illness severity.

The CDI Specialist will improve accuracy and completeness, understand PSI/HAC metrics, and write physician queries as needed, guiding clinicians and coders on documentation requirements.

Qualifikationen

• Experience in clinical documentation review and CDI practices.
• Strong understanding of PSI and HAC metrics in acute care.
• Ability to write physician queries for documentation clarification.

Aufgaben

• Review medical records for completeness and accuracy during hospitalization.
• Ensure documentation reflects services provided and patient illness severity.
• Provide guidance on documentation requirements to physicians, clinicians and coders.
• Serve as SME on coding rules and regulations.

Kenntnisse

Clinical documentation review

Physician queries

Coding rules & regulations

Quality metrics (PSI/HAC)

Jobbeschreibung

For questions regarding this position, please contact the Recruiter listed in the Supplemental Information section.

About The Position

Riverside University Health System – Medical Center is seeking an Inpatient Clinical Documentation Improvement (CDI) Specialist for the Health Information Management division. CDI Specialists review medical records to ensure documentation is complete, clear, accurate, and aligned with coding and documentation standards.

This role focuses on concurrent reviews during a patient’s hospital stay to confirm documentation reflects the services provided and the patient’s severity of illness. The CDI Specialist is experienced in clinical documentation review and capable of improving the accuracy, specificity, and completeness of patient‑care documentation. Ideal candidates will also have a strong understanding of PSI and HAC metrics, ensuring documentation and coding accurately reflect patient acuity and quality outcomes in an acute care setting. The role serves as a subject matter expert on coding rules and regulations, writes physician queries when clarification is needed, and provides guidance to physicians, clinicians, and coders on documentation requirements. This position requires deep knowledge of medical records, terminology, diagnoses, treatment plans, and clinical protocols.

Training will follow a 5/40, Monday–Friday onsite schedule, typically 8:00 a.m. to 4:30 p.m., with some flexibility in start times. After the employee demonstrates full competency