Clinical Documentation Improvement Specialist

Rc HR; Riverside (CA); On-site; USD 90,000 - 110,000; Full time

Job summary

Riverside University Health System – Medical Center is seeking an Inpatient CDI Specialist to join its Health Information Management division. The CDI role centers on concurrent chart reviews during a patient’s hospital stay to ensure documentation reflects services provided and patient severity of illness.

The CDI Specialist writes physician queries, guides physicians, clinicians and coders on documentation requirements, and contributes to quality outcomes.

Qualifications

• Experience in clinical documentation review.
• Inpatient CDI experience strongly preferred.
• Knowledge of ICD-10-CM and CPT-4 coding systems.

Responsibilities

• Complete admission reviews within 24 hours of admission to assign principal and secondary diagnoses and procedures for CMS-DRG.
• Initiate and perform concurrent reviews to clarify conditions and procedures.
• Develop and implement methods to improve documentation clarity, accuracy and completeness.

Skills

Clinical documentation review

Query physicians

Coding knowledge

Communication with clinicians

Data analysis

Education

Bachelor’s degree in nursing

Bachelor’s degree in health information management / health information technology

Doctor of Medicine degree

Tools

Encoder

Electronic abstracting system

Job description

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 in RUHS CDI processes and meets productivity expectations, they may transition to a hybrid schedule. Training duration will vary based on proficiency and performance.

Meet the Team! Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and is the only Pediatric ICU in the region. Can you see yourself here? For more information on RUHS-Medical Center, please visit ruhealth.org

• Complete admission reviews of patients' records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.
• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and conduct follow-up reviews as necessary.
• Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.
• Communicate with and serve as a resource for physicians, nurses and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.
• Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (i.e., ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by the Office of State Wide Hospital Planning and Development (OSHPD) and the Medical Audit Committee or individual physicians for various studies, statistical indexing and preparation of summary reports to various regulatory agencies.
• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.

OPTION I

Education: Graduation from an accredited college or university with a bachelor's degree in nursing.

Experience: Three years as a registered nurse in an acute care hospital. One year of inpatient CDI experience strongly preferred.

License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.

Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.

OPTION II

Education: Graduation from an accredited college or university with a bachelor's degree in health information management, health information technology or a related field to the assignment. (Additional qualifying experience may substitute for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education).

Experience: Four years of professional coding and abstracting medical records in a healthcare setting. One year of inpatient CDI experience strongly preferred.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association.

OPTION III

Education: Completion of Doctor of Medicine degree.

Experience: One year of clinical documentation improvement experience in a healthcare setting. One year of inpatient CDI experience strongly preferred.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in Clinical Documentation preferred.

ALL OPTIONS

Knowledge of: Coding, abstracting and terminology systems such as International Classification of Diseases, Clinically Modified (ICD-10) and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.

Ability to: Analyze and interpret the technical elements of a medical chart; analyze, code and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; effective communication skills. This recruitment is open to all applicants.

For additional information about this recruitment contact:

Angela Levinson

951-955-5562 or [e-mail]