Clinical Documentation Specialist
About The Position
The Clinical Documentation Integrity (CDI) Specialist reviews medical records to identify opportunities to clarify diagnoses and clinical conditions. The Specialist collaborates with providers, coders, and other healthcare team members to ensure accurate documentation that supports compliant reimbursement, quality reporting, regulatory requirements, and organizational performance. The role requires a high level of clinical knowledge about the patient population served, independent work with minimal supervision, and clear verbal and written communication with people at varying education levels. The position follows a hybrid schedule and requires the ability to use technology and appropriate software in daily activities, as well as to perform the job’s essential physical requirements.
Requirements
- Five years of recent experience in a clinical healthcare setting.
- A high level of clinical knowledge regarding the patient population served.
- Ability to work with minimal supervision.
- Ability to communicate verbally and in writing with individuals at varying education levels.
- Ability to use technology and appropriate software to support daily activities.
- Ability to perform the essential physical requirements of the job.
- A current California RN license, Nurse Practitioner qualification, Physician Assistant qualification, MD graduate/education in utilization review or a foreign country, Certified Clinical Documentation Specialist (CCDS), or Certified Documentation Improvement Practitioner (CDIP).
Nice To Haves
- Bachelor’s degree in a related field preferred.
- Prior experience in clinical documentation review.
- Understanding of ICD-10 coding requirements.
- CCS certification preferred but not required.
- CDS certification encouraged but not required.
Responsibilities
- Review medical records to identify opportunities to clarify diagnoses and clinical conditions.
- Collaborate with providers, coders, and other healthcare team members to support accurate documentation.
- Support compliant reimbursement, quality reporting, regulatory requirements, and organizational performance.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
