RN, Clinical Documentation Integrity Specialist

Jobtailor; Compton (CA); On-site; USD 110,000 - 140,000; Full time

Job summary

Jobtailor seeks an experienced Clinical Documentation Specialist (RN/NP) in California to perform comprehensive chart reviews and drive documentation integrity across outpatient care. You will craft evidence-based provider queries, educate clinicians, and support CMS-compliant documentation initiatives.

You will work with physicians, NPs, and care teams, leveraging CDI software and analytics to improve risk adjustment outcomes and support value-based care strategies. Bilingual Spanish is a plus.

Qualifications

• Active, unrestricted RN or NP license in California.
• Minimum of three years of clinical experience in outpatient/primary care settings.
• Ability to interpret, analyze, and synthesize clinical information across multi-source records.
• Foundational knowledge of ICD-10-CM coding principles and related documentation requirements.
• Strong written and verbal communication with clinicians and care teams.
• Proficiency with EHR systems, digital workflows, and documentation tools.
• Ability to work independently and prioritize in a fast-paced clinical environment.
• Attention to detail, analytical thinking, clinical judgment, problem-solving.
• Experience in CDI, risk adjustment, HCC coding, or documentation improvement.
• Familiarity with Medicare Advantage or value-based care models.
• Certifications: CRC, CDEO, CCDS-O, CDIP preferred; commitment to obtain within 12 months.

Responsibilities

• Conduct prospective, concurrent, and retrospective reviews of medical records to identify documentation gaps and HCC opportunities.
• Apply clinical reasoning to synthesize information across EMR docs, labs, imaging, meds, and notes.
• Review longitudinal chart trends to identify disease progression and documentation opportunities.
• Formulate compliant verbal and written provider queries with objective evidence.
• Partner with physicians, NPs, and clinical teams through chart-side discussion and education.
• Participate in interdisciplinary team meetings and real-time workflows.
• Prioritize and manage daily chart review workflows based on risk and organizational priorities.
• Track provider documentation patterns, query outcomes, and review activity using CDI tools.
• Develop provider-facing education, CDI resources, templates, and dashboards aligned with CMS standards.
• Conduct documentation quality reviews, surface deficiencies, and surface trends to CDI leadership.
• Contribute innovative ideas involving AI and perform other duties as assigned.

Skills

RN License

Clinical Documentation

ICD-10-CM Coding

EHR Proficiency

Risk Adjustment

Data Analysis

Communication

Education & Coaching

Bilingual Spanish

Education

CRC

CDEO

CCDS-O

CDIP

Tools

CDI Software Platforms

Reporting Dashboards

Documentation Tracking Systems

Job description

• Conduct prospective, concurrent, and retrospective reviews of medical records to identify documentation gaps, unsupported diagnoses, missed HCC opportunities, and clinically present conditions requiring provider assessment or clarification
• Apply clinical reasoning to synthesize information across EMR documentation, laboratory results, imaging reports, medications, specialist notes, and outside records
• Review longitudinal chart trends to identify disease progression, chronic condition indicators, and opportunities to improve documentation of participant complexity and severity of illness
• Formulate compliant verbal and written provider queries presenting clinical evidence objectively and supporting provider clarification without directing clinical conclusions
• Partner with physicians, nurse practitioners, and clinical teams through chart-side discussion, consultation, and structured education
• Participate in interdisciplinary team meetings and clinical workflows to surface documentation opportunities in real time
• Prioritize and manage daily chart review workflows based on risk stratification, HCC capture opportunities, documentation trends, and organizational priorities
• Track provider documentation patterns, query outcomes, capture rates, and review activity using CDI tracking tools and reporting systems
• Develop and support provider-facing education, CDI resources, query templates, workflow guides, and performance reports aligned with CMS documentation standards and organizational policy
• Conduct documentation quality reviews and expose deficiencies, unsupported diagnoses, condition validation concerns, compliance risks, and systemic trends to CDI program leadership
• Contribute innovative ideas involving AI and perform other duties as assigned

Requirements

• Active, unrestricted RN or NP license in the state of California
• Minimum of three years of clinical experience in an outpatient, primary care, ambulatory care, or comparable clinical setting
• Demonstrated ability to interpret, analyze, and synthesize clinical information across complex, multi-source medical records
• Foundational knowledge of ICD-10-CM coding principles and their relationship to clinical documentation requirements
• Strong written and verbal communication skills, with the ability to engage credibly and collaboratively with physicians, nurse practitioners, and clinical care teams
• Proficiency with electronic health record systems, digital workflows, and documentation or reporting tools
• Ability to work independently, manage a structured chart review workload, and prioritize effectively in a fast-paced clinical environment
• Strong attention to detail, analytical thinking, clinical judgment, and problem-solving skills
• Experience in clinical documentation integrity, risk adjustment, HCC coding, or documentation improvement, preferably in an outpatient, primary care, ambulatory care, or value-based care setting
• Familiarity with Medicare Advantage, PACE, capitated care, or other value-based care models
• CRC, CDEO, CCDS-O, CDIP, or comparable documentation/risk adjustment certification preferred; candidates without certification must demonstrate commitment to obtain certification within 12 months of hire
• Experience using CDI software platforms, risk adjustment analytics tools, reporting dashboards, or related documentation tracking systems
• Experience providing clinical provider education, including one-on-one coaching, chart-based feedback, and group education
• Preferred Bilingual Spanish a plus
• Tuberculosis screening upon hire or proof of a negative screening within the last year

Core Competencies

Demonstrates expertise in clinical documentation integrity, risk adjustment, and HCC coding, with a strong ability to analyze and synthesize complex medical records. Proficient in engaging with clinical teams and providing education aligned with CMS documentation standards.

Highest-signal resume keywords

• Active RN Or NP License
• Clinical Documentation Integrity
• ICD-10-CM Coding Principles
• Electronic Health Record Systems
• Risk Adjustment Analytics Tools

Hard Skills

• Clinical Experience
• Documentation Improvement
• Chart Review Workload Management
• Analytical Thinking
• Clinical Judgment

Soft Skills

• Strong Communication Skills
• Attention To Detail
• Problem-Solving Skills

Certifications & Qualifications

• CRC
• CDEO
• CCDS-O
• CDIP

Industry Keywords

• Medicare Advantage
• Value-Based Care
• Capitated Care
• Outpatient Care
• Ambulatory Care

Tools & Technologies

• CDI Software Platforms
• Reporting Dashboards
• Documentation Tracking Systems