Clinical Documentation Improvement Specialist

Riverside University Health System-Medical Center has an opportunity for an 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 classification is responsible for concurrent clinical documentation review, with an emphasis on completeness and accuracy of healthcare provider documentation related to types of medical services provided and the level of patient illness severity throughout hospital admission/discharge.

The CDI Specialist is experienced in clinical documentation review and capable of implementing methods of improving the accuracy, specificity, and completeness of patient-care documentation.

The major role of a CDI Specialist is to serve as an institutional subject matter expert and as a resource for interpretation and application of coding rules and regulations; and, when necessary, write physician queries to obtain additional documentation or clarification.

The incumbent provides guidance to physicians, clinicians, and coders regarding documentation requirements.

A CDI Specialist is expected to possess an in-depth understanding of the substantive contents of a medical record, including extensive knowledge of a wide variety of specialized medical terminology, as well as medical diagnosis, treatment plans, and protocols.

Ideal candidates will have a strong understanding of PSI and HAC metrics, and the ability to ensure accurate documentation and coding that appropriately reflects patient acuity and quality outcomes in an acute care environment.

These positions have either a Monday-Friday or a Tuesday-Saturday, 9/80, hybrid in-person/remote schedule.

Occasional travel will be required, as incumbents will rotate through the main hospital campus to provide CDI support and resources to clinical staff.

During initial training and departmental onboarding, incumbents will work on-site full-time

Meet the Team!
Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region.

The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and is the only Pediatric ICU in the region.

Can you see yourself here? For more information on RUHS-Medical Center, please visit ruhealth.org• Complete admission reviews of patients' records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.

• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and co...