Job Description

Inpatient Clinical Documentation Improvement Specialist Clinical Documentation Improvement (CDI) Specialists review medical record documentation to assure completeness, clarity, accuracy, and overall quality in accordance with Coding and Clinical Documentation Improvement goals. This role involves concurrent clinical documentation review with an emphasis on complete and accurate documentation of healthcare provider records related to the medical services provided and the level of patient illness severity throughout hospital admission and discharge. The CDI Specialist is an institutional subject matter expert and acts as a resource for interpretation and application of coding rules and regulations. When necessary, the specialist writes physician queries to obtain additional documentation or clarification, and provides guidance to physicians, clinicians, and coders regarding documentation requirements. The CDI Specialist possesses an in-depth understanding of the substantive contents of a medical record, including extensive knowledge of specialized medical terminology, diagnoses, treatment plans, and protocols. Schedule: Monday‑Friday or Tuesday‑Saturday, 9/80 hybrid in‑person/remote schedule with occasional travel required. Initial training and onboarding are on‑site full‑time. Responsibilities Complete admission reviews of patients' records within 24 hours of admission to evaluate and analyze documentation for principal, secondary diagnoses and procedures for accurate CMS‑DRG assignment. Initiate and conduct concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where documentation is inadequate or conflicting, and perform follow‑up reviews as necessary. 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 physicians, nurses and other healthcare providers to facilitate complete and accurate documentation, query missing or unclear records, obtain additional documentation, and inform physician leaders of documentation trends and learning opportunities. Code procedures and diagnoses according to ICD‑10‑CM (or subsequent adaptation) and CPT‑4 systems; prepare data from medical charts per OSHPD and audit committee or physician requests for studies, indexing and regulatory reporting. Collect data for performance improvement, report findings and outcomes, and participate in analysis of statistical data to identify opportunities for improvement. Participate in revenue cycle meetings, providing data related to reimbursement concerns, and educate providers on documentation matters related to coding, billing and reimbursements. Qualifications Option I Education: Bachelor's degree in nursing from an accredited institution. Experience: Three years as a registered nurse in an acute care hospital. One year of inpatient CDI experience strongly preferred. License/Certificate: Current valid license to practice as a Registered Nurse in the State of California. Must possess valid Basic Life Support (BLS) CPR and Automated External Defibrillator (AED) certificates issued by the American Heart Association. Option II Education: Bachelor's degree in health information management, health information technology or a related field, or equivalent experience (one year of full‑time experience equals 30 semester or 45 quarter units). Experience: Four years of professional coding and abstracting in a healthcare setting. One year of inpatient CDI experience strongly preferred. Certificate: Valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator from AHIMA. Option III Education: Doctor of Medicine degree. Experience: One year of clinical documentation improvement experience in a healthcare setting. One year of inpatient CDI experience strongly preferred. Certificate: Valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator from AHIMA; certification in Clinical Documentation preferred. All Options Knowledge of: Coding, abstracting and terminology systems such as ICD-10-CM and CPT‑4; comprehensive medical terminology across specialties; clinical documentation standards; federal, state and local laws and regulations; payer documentation requirements and reimbursement regulations. Ability to: Analyze and interpret technical elements of a medical chart; code and abstract complex data; prepare concise records and reports; establish effective working relationships with physicians and patients; communicate effectively. This recruitment is open to all applicants. Contact Angela Levinson 951‑955‑5562 alevinson@rivco.org #J-18808-Ljbffr County of Riverside

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