Senior Clinical Documentation & CDI Specialist

Kaiser Permanente; Pleasanton, Northern (CA, KY); Hybrid; USD 110,000 - 140,000; Full time

Job summary

Kaiser Permanente in Pleasanton, CA is seeking a Clinical Documentation Improvement (CDI) Specialist to review a moderate caseload of medical/health records, assign medical codes and DRGs, and promote accuracy and completeness of diagnoses. The role supports CDI program improvements, auditing, and education to ensure compliant documentation under federal regulations.

You will collaborate with cross-functional teams, provide training, and help resolve documentation issues while guiding staff

Qualifications

• Bachelor's degree in Nursing, Medicine, Health Administration, Health Information Management, or related field.
• Minimum two (2) years of experience in inpatient acute care or clinical setting OR seven (7) years in nursing, medicine, CDI, inpatient coding, quality review, or related field.

Responsibilities

• Promotes learning and provides guidance to coworkers and stakeholders to improve performance.
• Completes work autonomously and supports CDI-related projects with expertise and planning.
• Reviews medical records to ensure accurate documentation and assigns codes/DRGs in collaboration with senior staff.
• Supports CDI program improvements and documentation initiatives with cross-functional collaboration.
• Drives regulatory compliance through audits, documentation reviews, and adherence to federal, state, and local regulations.

Skills

Clinical documentation

Medical coding

Quality review

Team collaboration

Education

Bachelor's degree (Nursing/Medicine/Health Admin/Health Information Mgmt)

Job description

Kaiser Permanente in Pleasanton, CA is seeking a Clinical Documentation Improvement (CDI) Specialist to review a moderate caseload of medical/health records, assign medical codes and DRGs, and promote accuracy and completeness of diagnoses. The role supports CDI program improvements, auditing, and education to ensure compliant documentation under federal regulations.

You will collaborate with cross-functional teams, provide training, and help resolve documentation issues while guiding staff