Clinical Documentation Improvement Specialist Full Time Days

JOB SUMMARYCHA Hollywood Presbyterian Medical CenterCHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner.HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous fertility and research centers in the U.S. and Korea including CHA Fertility Center, a medical university, and CHAUM (a premier anti-aging life center).The Clinical Documentation Improvement (CDI) Specialist is responsible for ensuring the accuracy, completeness, and clinical validity of medical record documentation. This role works collaboratively with providers, coders, quality, and compliance teams to ensure documentation reflects the patient’s severity of illness, risk of mortality, quality outcomes, and supports accurate coding and reimbursement in compliance with regulatory standards.MAJOR RESPONSIBILITIES/ESSENTIAL FUNCTIONSEssential Duties and Responsibilities:Clinical Record ReviewPerform concurrent and/or retrospective reviews of inpatient and/or outpatient medical recordsIdentify documentation gaps, inconsistencies, and missing or unclear diagnosesValidate that clinical indicators support documented diagnosesEnsure documentation supports appropriate:Principal diagnosisSecondary diagnoses (CC/MCCs, HCCs)Procedures and POA statusSeverity of Illness (SOI) and Risk of Mortality (ROM)Provider Query and Communication:Initiate compliant, clinically sound provider queries to clarify diagnoses and proceduresEnsure queries follow organizational, ACDIS, and AHIMA guidelinesTrack query response rates and outcomesProvide real-time documentation feedback to providersProvider EducationEducate providers on documentation best practices, clinical definitions, and regulatory requirementsIdentify trends in documentation opportunities and deliver targeted educationSupport new provider onboarding related to documentation expectationsCollaboration & Interdisciplinary WorkWork closely with coding professionals to ensure documentation supports accurate code assignmentCollaborate with quality, case management, utilization review, and compliance teamsSupport audit readiness and payer review responsesQuality, Compliance & Risk AdjustmentSupport quality metrics, including mortality, complications, readmissions, and patient safety indicatorsAssist in risk adjustment and hierarchical condition category (HCC) capture where applicableParticipate in internal and external auditsEnsure adherence to CMS, payer, and organizational documentation standardsData Tracking & ReportingMonitor and report CDI performance metrics, including:Query rates and response timesDocumentation improvement trendsPerforms all other duties as assigned or required.JOB QUALIFICATIONSMinimum Education/Certification (Indicate minimum education or degree required.)Clinical licensure or certification (RN, MD, DO, PA, NP, ECFMG, or equivalent clinical background)Minimum 1-2 years of recent clinical or CDI-related and/or coding experienceStrong knowledge of:1) Disease processes and clinical indicators2) ICD-10-CM/PCS coding concepts3) DRG, SOI/ROM, and/or HCC methodologies4) Excellent written and verbal communication skills5) Proficiency with electronic health records (EHRs)Preferred Education/Certification (Indicate preferred education or degree required.)CDI certification (CCDS, CCDS-O, CDIP)Coding certification (CCS, CPC, RHIA, RHIT)Prior experience in acute care, outpatient CDI, or risk adjustmentFamiliarity with ACDIS and AHIMA CDI guidelinesMinimum Work Experience and Qualifications (Indicate minimum years of job experience, skills or abilities required for the job.)Clinical critical thinking and analytical skillsProfessional provider communication and conflict resolutionAttention to detail and accuracyAbility to work independently and collaborativelyStrong organizational and time-management skillsPreferred Work Experience and Qualifications (Indicate preferred years of job experience, skills or abilities required for the job.)N/ARequired Licensure, Certification, Registration or Designation (List any licensure or certification required and specify name of agency.)Current Los Angeles County Fire Card (required within 30 days of employment)Assault Response Competency (ARC) (required within 30 days of employment)Status: Full Time (On-Site)Shift: DaysHours: 8hrsWeekly/Bi-Weekly Hours: 40hrs/80hrsFTE: 1.0