Clinical Documentation Specialist — CDI & Medical Records Expert

Pioneers Memorial Healthcare District; Brawley (CA); On-site; USD 73,000 - 86,000; Full time

Job summary

Pioneers Memorial Healthcare District in Brawley, CA seeks a Clinical Documentation Specialist (Full Time) to review medical records and facilitate accurate severity of illness representations. You will collaborate with physicians, HIM professionals, and nursing staff to ensure CDMP alignment and proper documentation practices.

Responsibilities include learning CDMP processes, precise data input into CDMP Trak, resolving discrepancies, and participating in cross‑functional meetings to improve

Qualifications

• RN license required and CPR certification.
• Experience with hospital records and CDMP preferred.
• Strong written and verbal communication with clinical staff.

Responsibilities

• Review medical records to accurately represent severity of illness.
• Interact with physicians, HIM professionals, and nursing staff.
• Input data into CDMP Trak and support CDMP documentation strategies.
• Communicate discrepancies and resolve issues with care teams.
• Participate in Task Force Meetings and staff education.

Skills

Organizational skills

Analytical thinking

Writing ability

Interpersonal skills

Communication with physicians

Critical thinking

Education

RN license

BSN preferred

Tools

CDMP Trak

Job description

Pioneers Memorial Healthcare District in Brawley, CA seeks a Clinical Documentation Specialist (Full Time) to review medical records and facilitate accurate severity of illness representations. You will collaborate with physicians, HIM professionals, and nursing staff to ensure CDMP alignment and proper documentation practices.

Responsibilities include learning CDMP processes, precise data input into CDMP Trak, resolving discrepancies, and participating in cross‑functional meetings to improve