Clinical Documentation Specialist

San Antonio Community Hospital; Upland (CA); Hybrid; USD 66,000 - 99,000; Full time

Job summary

The Clinical Documentation Integrity (CDI) Specialist at San Antonio Community Hospital reviews medical records to identify opportunities to clarify diagnoses and clinical conditions, ensuring documentation supports compliant reimbursement and quality reporting.

You will collaborate with providers, coders, and the care team to optimize documentation while meeting regulatory requirements and organizational performance. Hybrid schedule offered in California.

Qualifications

• Bachelor’s Degree in related field preferred.
• 5 years of recent experience in a clinical health care setting.
• Prior experience in clinical documentation review preferred and understanding of ICD 10 coding requirements.
• Current CA RN License or equivalent (Nurse Practitioner, Physician Assistant, MD) with CCDS/CDIP encouraged.

Responsibilities

• Review medical records to identify opportunities to clarify diagnoses and clinical conditions.
• Collaborate with providers, coders, and the care team to ensure compliant documentation.
• Support reimbursement, quality reporting, regulatory requirements, and organizational performance.

Skills

Clinical knowledge

Verbal & written communication

Team collaboration

Education

Bachelor's degree in related field

Job description

Overview

JOB SUMMARY

The Clinical Documentation Integrity (CDI) Specialist reviews medical records to identify opportunities to clarify diagnoses and clinical conditions. The CDI Specialist collaborates with providers, coders, and other healthcare team members to ensure accurate documentation that supports compliant reimbursement, quality reporting, regulatory requirements, and organizational performance.

MINIMUM QUALIFICATIONS

Education: Bachelor’s Degree in related field preferred.

Experience: 5 years of recent experience in clinical health care setting. Prior experience in clinical documentation review preferred as well as an understanding of ICD 10 coding requirements.

Knowledge and Skills: Must possess a high level of clinical knowledge regarding the patient population served in order to participate collaboratively with all member of the care team. Works with minimal supervision, must be able to communicate verbally and written to individuals of varying education levels.

License/Certifications: Current CA RN License, Nurse Practitioner, Physician Assistant, MD graduate/educated in UR or foreign country, Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP). CDS certification is encouraged but not required. CCS is preferred but not required.

Equipment: Demonstrated ability to use technology and appropriate software to support in their daily activities.

Physical Requirements: Must be able to perform the essential physical requirements of the job. Must be able to work hybrid schedule.

PAY RANGE

$47.90 - $71.84

The posted pay range reflects the lowest to highest pay that was available for this position at the time of posting and may be subject to change. Salary offers are determined by candidate’s relevant experience and skills.For per diem positions, a standard rate is used based on market data and not the candidate’s individual experience.