Clinical Documentation Improvement Specialist

County of Riverside • Riverside, CA

3d • Hybrid

About The Position

Riverside University Health System–Medical Center is seeking an Inpatient Clinical Documentation Improvement (CDI) Specialist for its Health Information Management division. The role performs concurrent medical-record reviews during patients’ hospital stays to ensure documentation is complete, clear, accurate, and aligned with coding and documentation standards, reflecting the services provided and patients’ severity of illness. The specialist is expected to improve the accuracy, specificity, and completeness of patient-care documentation and to understand PSI and HAC metrics in an acute-care setting.

The CDI Specialist serves as a subject matter expert on coding rules and regulations, writes physician queries when clarification is needed, and guides physicians, clinicians, and coders on documentation requirements. The position requires knowledge of medical records, terminology, diagnoses, treatment plans, and clinical protocols.

Training is onsite on a 5/40, Monday–Friday schedule, typically 8:00 a.m. to 4:30 p.m., with some flexibility in start times. After demonstrating competency in RUHS CDI processes and meeting productivity expectations, the employee may transition to a hybrid schedule. Training duration varies according to proficiency and performance.

Requirements

• Meet one of the stated qualification pathways: Option I requires a bachelor's degree in nursing and three years of registered-nurse experience in an acute-care hospital; Option II requires a bachelor's degree in health information management, health information technology, or a related field and four years of professional medical-record coding and abstracting experience in a healthcare setting; Option III requires a Doctor of Medicine degree and one year of clinical documentation improvement experience in a healthcare setting.
• For Option I, hold and maintain a current valid California Registered Nurse license.
• For Option I, hold valid American Heart Association BLS/CPR and AED certificates for professional healthcare providers.
• For Option II, hold a valid AHIMA-issued Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) certification.
• For Option III, hold a valid AHIMA-issued CCS, RHIT, or RHIA certification.
• Know coding, abstracting, and terminology systems such as ICD-10 and CPT-4; comprehensive medical terminology across specialties; clinical documentation standards; applicable nursing laws and regulations; payor documentation requirements; and governmental reimbursement regulations.
• Be able to analyze and interpret technical elements of medical charts; analyze, code, and abstract complex data across specialties using an encoder and electronic abstracting system; prepare and maintain concise, complete records and reports; establish effective working relationships; and communicate effectively.

Nice To Haves

• One year of inpatient CDI experience is strongly preferred.
• Certification in Clinical Documentation is preferred.

Responsibilities

• Complete admission reviews of patient records within 24 hours of admission; evaluate documentation and assign principal and pertinent secondary diagnoses and procedures to support accurate and optimal CMS-DRG assignment.
• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions, diagnoses, and procedures when documentation is inadequate or conflicting, and conduct follow-up reviews as needed.
• Develop and implement methods to improve the clarity, accuracy, and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status updates to medical center departments and committees.
• Communicate with and serve as a resource for physicians, nurses, and other healthcare providers to facilitate complete and accurate patient records.
• Query physicians about missing, unclear, or conflicting documentation and obtain additional documentation; keep physician leaders informed about relevant data, documentation trends, and opportunities for learning and improvement.
• Code procedures and primary and secondary diagnoses using applicable ICD-10-CM or subsequent adaptation and CPT-4 coding systems.
• Prepare medical-chart data according to OSHPD and Medical Audit Committee or individual physician criteria for studies, statistical indexing, and summary reports to regulatory agencies.
• Collect data for performance improvement, report findings and outcomes, and participate in analysis and trending of statistical data for patient populations to identify improvement opportunities.
• Participate in revenue cycle meetings and provide data related to reimbursement concerns.
• Educate physicians and healthcare providers about documentation matters related to coding, billing, and reimbursement.

What This Job Offers

• Job Type: Full-time