Senior Clinical Documentation Improvement Specialist

Sharp HealthCare; Oceanside (CA); On-site; USD 163,328,000 - 215,508,000; Full time

Job summary

Sharp HealthCare is seeking a Clinical Documentation Improvement Specialist to perform concurrent review of medical records, issuing physician inquiries, and coordinating with medical staff to improve documentation quality.

You will lead CDI initiatives, educate clinical teams, and ensure regulatory compliance while supporting accurate reimbursement within a CA-based hospital system. This role requires a nursing background and CDI certification.

Qualifications

• Bachelor's Degree in Nursing is required.
• Minimum 5 years of Registered Nurse experience.
• At least 2 years of RN experience in Clinical Documentation Improvement.
• California RN license (CA Board) required.
• Current CDI certification through ACDIS is REQUIRED.

Responsibilities

• Review medical records for completeness and accuracy and identify missing information.
• Query providers to clarify inconsistent or incomplete documentation in an ethical, compliant manner.
• Collaborate with physicians, nurses, coders, and other staff to improve record quality.
• Develop and implement CDI policies, education, training, and performance measurements.
• Ensure regulatory compliance (HIPAA, Joint Commission, OSHA) and prevent denials.

Education

Bachelor's Degree in Nursing

California Registered Nurse (RN) License

Registered Nurse (RN) with Clinical Documentation Improvement experience

Current CDI certification through ACDIS

RHIA/RHIT/CCS/ACM/CCM certifications (preferred)

Job description

Sharp HealthCare is seeking a Clinical Documentation Improvement Specialist to perform concurrent review of medical records, issuing physician inquiries, and coordinating with medical staff to improve documentation quality.

You will lead CDI initiatives, educate clinical teams, and ensure regulatory compliance while supporting accurate reimbursement within a CA-based hospital system. This role requires a nursing background and CDI certification.