Clinical Documentation Improvement Specialist

Hours: Shift Start Time: 7:30 AM, Shift End Time: 4:00 PM. AWS Hours Requirement: 8/40 - 8 Hour Shift. Additional Shift Information: Weekend Requirements: Every Other. On-Call Required: No. Hourly Pay Range (Minimum - Midpoint - Maximum): $57,740 - $74,490 - $83,440. What You Will Do: The Clinical Documentation Improvement Specialist (CDIS) reviews inpatient medical records while patients are still in-house (concurrent review) for proper documentation resulting in appropriate reimbursement, severity of illness, risk of mortality, quality measures and risk adjustment. This review includes new admissions to the facility, as well as re-reviews every two to three days until the patients are discharged. The CDIS communicates with clinicians and physicians to ensure timely and accurate documentation for all designated payer(s) and provides training and education as needed. The role collaborates with many departments such as HIM, Quality, and Service lines to improve documentation, reimbursement and quality measures internally for Sharp Healthcare as well as publicly reported measures. Responsibilities Review inpatient medical records for documentation quality and coding compliance. Conduct concurrent reviews during patient stay and re-review every 2-3 days until discharge. Communicate with clinicians and physicians to ensure proper documentation and assistance with queries. Provide real-time interactive communication and education to improve diagnosis and procedure documentation. Collaborate with HIM, Quality, Service lines, and clinical coding specialists to achieve improved reimbursement and quality metrics. Required Qualifications 5+ years of experience in nursing or other clinical role in an acute care facility. Registered Nurse (RN) – California Board of Registered Nursing required. Preferred Qualifications Bachelor's Degree in Nursing. Emergency or critical care nursing background. Experience working with an EHR, preferably Cerner Millennium. CDIS certification preferred. Essential Functions & Key Skills Code compliance – collaborate with coding specialists and second level reviewers, facilitate physician queries, and document clarifications. Communication and teamwork – maintain positive, respectful, and collaborative relationships with all team members. Documentation – improve accuracy, specificity, and completeness through education and real-time queries. Leadership in area of expertise – collaborate with informaticists, recommend workflow and technical improvements. Professional development – stay current with coding guidelines, participate in training and peer review processes. Quality – work with the Quality Team to align documentation with safety indicators, hospital-acquired conditions, and risk adjustment diagnoses. Knowledge, Skills & Abilities Strong clinical understanding of disease processes, pathophysiology, and treatment plans; effective interpersonal, organizational, prioritization, written and verbal communication, analytical skills; proficiency with MS Office; knowledge of regulatory coding guidelines preferred. Equal Opportunity Statement Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with disability or any other protected class. #J-18808-Ljbffr