Clinical Documentation Specialist - Hybrid CDI Role

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

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.