Clinical Documentation Specialist

San Antonio Regional Hospital; Upland (CA); Hybrid; USD 65,000 - 99,000; Full time

Job summary

San Antonio Regional Hospital seeks a Clinical Documentation Integrity (CDI) Specialist to review medical records and identify opportunities to clarify diagnoses and clinical conditions. You will collaborate with providers, coders, and the care team to ensure accurate documentation that supports compliant reimbursement and regulatory requirements.

The role emphasizes close teamwork, effective written and verbal communication, and the ability to work in a hybrid schedule while supporting

Qualifications

• Bachelor’s Degree in related field preferred.
• 5 years of recent experience in a clinical health care setting.
• Experience in clinical documentation review and ICD-10 knowledge.
• High level of clinical knowledge regarding the patient population served.
• Ability to communicate verbally and in writing to individuals with varying education levels.
• Current CA RN License, Nurse Practitioner, Physician Assistant, MD with UR/CDIS/CDIP; CCS encouraged but not required.
• Demonstrated ability to use technology and appropriate software.
• Must be able to perform the essential physical requirements and work a hybrid schedule.

Responsibilities

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

Skills

Clinical knowledge

Communication

Team collaboration

Education

Bachelor's degree

Job description

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.

Overview

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.