Inpatient Clinical Documentation Improvement Specialist

Rc HR; Riverside (CA); On-site; USD 90,000 - 110,000; Full time

Job summary

Riverside University Health System – Medical Center is seeking an Inpatient CDI Specialist to join its Health Information Management division. The CDI role centers on concurrent chart reviews during a patient’s hospital stay to ensure documentation reflects services provided and patient severity of illness.

The CDI Specialist writes physician queries, guides physicians, clinicians and coders on documentation requirements, and contributes to quality outcomes.

Qualifications

• Experience in clinical documentation review.
• Inpatient CDI experience strongly preferred.
• Knowledge of ICD-10-CM and CPT-4 coding systems.

Responsibilities

• Complete admission reviews within 24 hours of admission to assign principal and secondary diagnoses and procedures for CMS-DRG.
• Initiate and perform concurrent reviews to clarify conditions and procedures.
• Develop and implement methods to improve documentation clarity, accuracy and completeness.

Skills

Clinical documentation review

Query physicians

Coding knowledge

Communication with clinicians

Data analysis

Education

Bachelor’s degree in nursing

Bachelor’s degree in health information management / health information technology

Doctor of Medicine degree

Tools

Encoder

Electronic abstracting system

Job description

Riverside University Health System – Medical Center is seeking an Inpatient CDI Specialist to join its Health Information Management division. The CDI role centers on concurrent chart reviews during a patient’s hospital stay to ensure documentation reflects services provided and patient severity of illness.

The CDI Specialist writes physician queries, guides physicians, clinicians and coders on documentation requirements, and contributes to quality outcomes.