Clinical documentation specialist [h1.location_city]

ESSENTIAL JOB FUNCTIONS AND CORE RESPONSIBILITIES

• Assist and develop tracking mechanisms to demonstrate program impact.
• Assist in the development plans for both formal and informal education for physicians, nursing, and other clinical staff.
• Meets established productivity targets for record review and appropriate query placement.
• Demonstrates working knowledge of ICD-10 CM and ICD-10-PCS coding conventions and guidelines and applies to ongoing evaluation of medical record documentation.
• Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation.
• Facilitates multidisciplinary team in efforts for clinical documentation improvement.
• Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
• Improve overall quality and completeness of clinical documentation in the medical record in accordance with all regulatory requirements.
• Reviews inpatient Medical Record for identified payor populations on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
• Works collaboratively with coding staff to assure documentation of discharge diagnoses and any coexisting / comorbidities area complete reflection of the patient's clinical status and care.
• Other duties as assigned.

JOB REQUIREMENTS

Education

Minimum (Required)

Preferred (Not required)

Work Experience

Minimum (Required)

Preferred (Not required)

Licenses and Certifications

Minimum (Required)

Preferred (Not required)

Pay Transparency

The hourly rate range for this position is $46.27 - $60.73 When extending an offer of employment, the University of Southern California Arcadia Hospital considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education / training, key skills, internal peer equity, federal, State, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations .

POSITION SUMMARY The CDI Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the specificity of the physicians' clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Involved with educational activities to maintain up-to-date information on Medicare, ICD-10, and CPT coding, and documentation guidelines. Active participation in team meetings by providing recommendations on query structure, process, and workflow. Responds to coding denials with clinical justifications and coding conventions. Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and adheres to HIPAA regulations. Keep the CDI team and HIM Manager or Director informed of workflow status and potential backlog issues. Job ID REQ20169584 Posted Date 11 / 24 / 2025 Apply Save Job Current employees apply here