Clinical Documentation Integrity Specialist

Loma Linda University Health; Loma Linda (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

The Clinical Documentation Specialist at Loma Linda University Health conducts concurrent reviews to ensure accurate and complete provider documentation regarding patient condition and care during hospitalization. The role involves proactive communication with clinicians to clarify documentation needs and to improve record quality.

Responsibilities include providing formal education on documentation integrity at staff meetings and committees, and informing physician leaders of trends and

Qualifications

• Bachelor's degree required in nursing or HIM; progress in nursing acceptable with updates.
• RN license with California registration is required for the role.
• Clinical experience in acute hospital settings is essential.

Responsibilities

• Perform concurrent clinical documentation reviews focusing on accuracy and completeness.
• Communicate with providers to obtain clarifications for documentation gaps.
• Educate medical staff on documentation integrity in meetings and committees.

Skills

Clinical documentation

Communication

Critical thinking

Education delivery

Team collaboration

Education

Bachelor's degree in Nursing

Bachelor's degree in Health Information Management

Nursing in progress acceptable

Tools

EMR systems

Job description

The Clinical Documentation Specialist at Loma Linda University Health conducts concurrent reviews to ensure accurate and complete provider documentation regarding patient condition and care during hospitalization. The role involves proactive communication with clinicians to clarify documentation needs and to improve record quality.

Responsibilities include providing formal education on documentation integrity at staff meetings and committees, and informing physician leaders of trends and