Clinical Documentation Improvement Specialist

Job Summary Riverside University Health System‑Medical Center is looking for an Inpatient Clinical Documentation Improvement Specialist . Roles and responsibilities include ensuring medical record documentation is complete, clear, accurate, and meets coding and CDI goals. The specialist reviews inpatient and outpatient records, initiates concurrent documentation reviews, develops improvement methods, and collaborates with physicians, nurses, and coders. Positions offer a Monday‑Friday or Tuesday‑Saturday, 9/80 hybrid schedule. Occasional travel is required to rotate through the main campus, and initial training is conducted on‑site full‑time. Key Responsibilities Complete admission reviews of patients' records within 24 hours to assign principal diagnosis, secondary diagnoses, and procedures for accurate CMS‑DRG assignment. Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions, diagnoses, and procedures where documentation is inadequate or conflicting, and conduct follow‑up reviews as necessary. Develop and implement methods to improve the clarity, accuracy, and completeness of clinical documentation; monitor and evaluate coding outcomes and provide status updates to departments and committees. Communicate with and serve as a resource for physicians, nurses, and other providers to facilitate complete and accurate documentation; query physicians regarding missing, unclear, or conflicting documentation and obtain additional records; keep physician leaders informed of trends and opportunities for learning and improvement. Code procedures and diagnoses using ICD‑10‑CM and CPT‑4 systems; prepare data according to OSHPD and regulatory agency criteria; contribute to summary reports. Collect data for performance improvement, analyze and trend statistical data for specified patient populations to identify improvement opportunities. Participate in revenue‑cycle meetings, providing data on reimbursement concerns; educate stakeholders on documentation matters related to coding, billing, and reimbursements. Education and Experience Options Option I – Registered Nurse Education: Graduation from an accredited college or university with a bachelor’s degree in nursing. Experience: Three years as a registered nurse in an acute‑care hospital; one year of inpatient CDI experience strongly preferred. License/Certificate: Valid and current California Registered Nurse license; valid BLS, CPR, and AED certificates issued by the American Heart Association. Option II – Health Information Professional Education: Bachelor’s degree in health information management, health information technology, or a related field (or equivalent experience). Experience: Four years of professional coding and abstracting experience; one year of inpatient CDI experience strongly preferred. Certification: Valid Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator certification from AHIMA. Option III – Medical Doctor Education: Doctor of Medicine degree. Experience: One year of clinical documentation improvement experience, with inpatient CDI experience strongly preferred. Certification: Valid Calder coding certification (CCS) or similar; Clinical Documentation certification preferred. All Options – Knowledge and Skills Knowledge of: ICD‑10‑CM, Clinically Modified ICD‑10, CPT‑4; comprehensive medical terminology across specialties; clinical documentation standards; federal, state, and local laws; payer source documentation requirements and reimbursement regulations. Ability to: Analyze and interpret technical medical chart elements; code and abstract complex data using an encoder and electronic abstracting system; prepare concise and complete records and reports; maintain effective working relationships with physicians, patients, and employees; and communicate effectively. #J-18808-Ljbffr County of Riverside