Senior Clinical Documentation Specialist (CDI)

UCI Health; Irvine (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

UCI Health is seeking a Clinical Documentation Specialist to improve the quality and accuracy of medical record documentation. You will audit records, solicit physician clarification, and educate teams on documentation guidelines to ensure proper data and reimbursement.

The role requires extensive clinical experience (RN or physician) with CDI expertise, strong communication, and collaboration across departments.

Qualifications

• Five or more years of clinical experience as either an RN or Physician and 3 years’ CDI experience.
• Familiarity with Joint Commission and CMS requirements and coding guidelines.
• Excellent written and verbal communication in English and ability to educate others on documentation guidelines.

Responsibilities

• Audit and evaluate the medical record for quality, completeness and accuracy.
• Solicit clarity from physicians when specificity is needed for accurate data and reimbursement.
• Educate staff on documentation guidelines and provide actionable recommendations.

Skills

Clinical knowledge

Customer service

Verbal communication

Written communication

Critical thinking

Collaborate with physicians

Education

Bachelor of Science in Nursing or Medical School Graduate

CDI Credential (CCDS or CDIP)

Master’s degree in health care related field

Tools

EPIC

3M 360 Encompass CAC

Job description

UCI Health is seeking a Clinical Documentation Specialist to improve the quality and accuracy of medical record documentation. You will audit records, solicit physician clarification, and educate teams on documentation guidelines to ensure proper data and reimbursement.

The role requires extensive clinical experience (RN or physician) with CDI expertise, strong communication, and collaboration across departments.