Clinical Documentation Specialist

San Antonio Regional Hospital • Upland, CA

1d • $48 - $72 • Hybrid

About The Position

The Clinical Documentation Integrity (CDI) Specialist reviews medical records to identify opportunities to clarify diagnoses and clinical conditions. The CDI 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.

Requirements

• Bachelor’s Degree in related field preferred.
• 5 years of recent experience in clinical health care setting.
• Prior experience in clinical documentation review preferred.
• Understanding of ICD 10 coding requirements.
• High level of clinical knowledge regarding the patient population served.
• Ability to participate collaboratively with all members of the care team.
• Ability to work with minimal supervision.
• Ability to communicate verbally and written to individuals of varying education levels.
• Current CA RN License, Nurse Practitioner, Physician Assistant, MD graduate/educated in UR or foreign country.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP).
• Demonstrated ability to use technology and appropriate software to support in their daily activities.
• Must be able to perform the essential physical requirements of the job.
• Must be able to work hybrid schedule.

Nice To Haves

• CDS certification is encouraged but not required.
• CCS is preferred but not required.

Responsibilities

• Reviews medical records to identify opportunities to clarify diagnoses and clinical conditions.
• Collaborates with providers, coders, and other healthcare team members to ensure accurate documentation that supports compliant reimbursement, quality reporting, regulatory requirements, and organizational performance.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior