Clinical Document Improvement Specialist
Pacer Group
Clinical Document Improvement Specialist
Location: Orange, CA (92868) Duration: 52 Weeks
Shift Details:
- Day Shift: Monday Friday (5x8 Hours)
- Timing: 8:00 AM 5:00 PM
- Weekend Coverage Required
- Work Mode: Hybrid
Position Summary
The Clinical Documentation Specialist (CDI) is responsible for improving the overall quality, accuracy, and completeness of clinical documentation. This role involves detailed medical record review, collaboration with healthcare providers, and ensuring compliance with regulatory standards to support accurate coding, quality reporting, and reimbursement.
Key Responsibilities
- Review inpatient adult medical records across UCI Health facilities for accuracy, completeness, and compliance
- Validate DRGs and identify documentation gaps
- Initiate and manage physician queries to clarify documentation
- Collaborate with physicians, coders, and clinical teams
- Ensure documentation reflects severity of illness and risk of mortality
- Educate providers on documentation best practices and guidelines
- Analyze data and generate reports with actionable insights
Required Qualifications
- Strong clinical knowledge with ability to interpret complex medical documentation
- Minimum 5+ years of clinical experience (RN or Physician)
- Minimum 3+ years of CDI (Clinical Documentation Improvement) experience
- Familiarity with Utilization Review criteria
- Knowledge of Joint Commission and CMS regulations
- Active CDI Certification (CCDS or CDIP)
Vacancy posted 5 days ago
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