Clinical Document Improvement Specialist II - Sharp Tri-City Medical Center

• Regular
• Responsibilities

Hours

Shift Start Time

7 AM

Shift End Time

4:30 PM

AWS Hours Requirement

8/40 -

• 8 Hour Shift

Additional Shift Information

Weekend

Requirements

Every Other

On-Call Required

No

Hourly Pay Range (Minimum - Midpoint - Maximum)

$57.000 - $66.110 - $75.210

This position is covered by a Collective Bargaining Agreement (CBA) with CNA.

What You Will Do The Clinical Documentation Improvement Specialist (CDI) performs concurrent review of medical records. Issues concurrent physician inquiries, and interacts with the medical staff and other healthcare staff in an effort to assure complete and accurate documentation of the patient's clinical picture and the treatment provided. The CDI acts as a liaison between case management, coding professionals and the medical staff. The CDI is responsible for improving overall quality and completeness of clinical documentation.

Required Qualifications Bachelor's Degree in Nursing 5 Years Registered Nurse experience. 2 Years Registered Nurse in Clinical Documentation Improvement experience. California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

Preferred Qualifications Experience with referral management system. Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA) -PREFERRED Registered Health Information Technician (RHIT) - The American Health Information Management Association (AHIMA) -PREFERRED Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) -PREFERRED Accredited Case Manager (ACM) - American Case Management Association (ACMA) -PREFERRED Certified Case Manager (CCM) - Commission for Case Manager Certification -PREFERRED

Other Qualification Requirements Current CDI certification through the Association of Clinical Documentation Improvement Specialists (ACDIS). - REQUIRED

Essential Functions

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization. Maintains a safe, clean working environment, including unit based safety and infection control requirements.

Clinical Documentation Improvement

Review medical records for completeness and accuracy, identifying any missing or unclear information regarding diagnoses, treatments, and care plans. Analyze documentation to clarify and validate diagnoses, ensuring accurate Diagnostic Related Group (DRG) assignment, severity of illness, risk of mortality, and case mix data. Collaborate with physicians, nurses, coders, and other healthcare staff to address documentation gaps and improve overall record quality.

Query providers to clarify inconsistent or incomplete documentation in an ethical, compliant manner. Facilitate accurate reimbursement by tracking insurance queries and ensuring providers receive appropriate compensation for their services. Develop CDI policies and procedures around query processes, education, training, and performance measurements.

Report and analyze data for quality improvement purposes, preparing feedback for team members and leadership. Completes concurrent review of assigned population; achieving a high accuracy rate.

Safety and Compliance

Maintain a safe, clean working environment, adhering to infection control and hospital policies. Monitor and audit records to ensure regulatory compliance (including HIPAA), prevent fraud, and avoid unnecessary insurance denials. Comply with regulatory standards (e.g., The Joint Commission, OSHA). Identify and report safety concerns proactively.

Professional Development and Leadership

Provide education to clinical staff on proper documentation practices and coding criteria, including ongoing training and development. Participate in program meetings, staff education, development activities, and in-service opportunities. Analyze trends and data to recommend process improvements for accurate clinical documentation.

Develop and implement formal and informal education plans for physicians, nurses and clinical staff to improve accuracy in clinical documentation. Provide preceptorship and mentorship to New Graduate Nurses, New Hires, and students, supporting their professional development. Serve as a resource for best practices within Clinical Documentation & Case Management/Utilization Review.

Knowledge, Skills, and Abilities Proficient computer skills, including Word. Knowledge and understanding of various payer types. Knowledge of ICD-10-CM coding conventions, risk adjustment models, and Hierarchical Condition Category Coding (HCC). Expert knowledge of clinical care and coding guidelines. Detail-oriented approach to reviewing and improving medical documentation. Strong prioritization skills. Self-motivated, independent thinker. Strong communication, teamwork, analytical, and leadership skills. Ability to analyze, educate, and communicate effectively with diverse clinical teams.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Associate's Degree in Nursing; Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA); Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA); Accredited Case Manager (ACM) - American Case Management Association (ACMA); Registered Health Information Technician (RHIT) - The American Health Information Management Association (AHIMA); Certified Case Manager (CCM) - Commission for Case Manager Certification; California Registered Nurse (RN) - CA Board of Registered Nursing; Bachelor's Degree in Nursing