Clinical Documentation Improvement Specialist Full Time Days

JOB SUMMARY

CHA Hollywood Presbyterian Medical Center

CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner.

HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous fertility and research centers in the U.S. and Korea including CHA Fertility Center, a medical university, and CHAUM (a premier anti-aging life center).

The Clinical Documentation Improvement (CDI) Specialist is responsible for ensuring the accuracy, completeness, and clinical validity of medical record documentation. This role works collaboratively with providers, coders, quality, and compliance teams to ensure documentation reflects the patient’s severity of illness, risk of mortality, quality outcomes, and supports accurate coding and reimbursement in compliance with regulatory standards.

MAJOR RESPONSIBILITIES/ESSENTIAL FUNCTIONS

Essential Duties and Responsibilities:

Clinical Record Review

• Perform concurrent and/or retrospective reviews of inpatient and/or outpatient medical records
• Identify documentation gaps, inconsistencies, and missing or unclear diagnoses
• Validate that clinical indicators support documented diagnoses
• Ensure documentation supports appropriate:
• Principal diagnosis
• Secondary diagnoses (CC/MCCs, HCCs)
• Procedures and POA status
• Severity of Illness (SOI) and Risk of Mortality (ROM)

Provider Query and Communication:

• Initiate compliant, clinically sound provider queries to clarify diagnoses and procedures
• Ensure queries follow organizational, ACDIS, and AHIMA guidelines
• Track query response rates and outcomes
• Provide real-time documentation feedback to providers

Provider Education

• Educate providers on documentation best practices, clinical definitions, and regulatory requirements
• Identify trends in documentation opportunities and deliver targeted education
• Support new provider onboarding related to documentation expectations

Collaboration & Interdisciplinary Work

• Work closely with coding professionals to ensure documentation supports accurate code assignment
• Collaborate with quality, case management, utilization review, and compliance teams
• Support audit readiness and payer review responses

Quality, Compliance & Risk Adjustment

• Support quality metrics, including mortality, complications, readmissions, and patient safety indicators
• Assist in risk adjustment and hierarchical condition category (HCC) capture where applicable
• Participate in internal and external audits
• Ensure adherence to CMS, payer, and organizational documentation standards

Data Tracking & Reporting

• Monitor and report CDI performance metrics, including:
• Query rates and response times
• Documentation improvement trends

Performs all other duties as assigned or required.

JOB QUALIFICATIONS

Minimum Education/Certification (Indicate minimum education or degree required.)

• Clinical licensure or certification (RN, MD, DO, PA, NP, ECFMG, or equivalent clinical background)
• Minimum 1-2 years of recent clinical or CDI-related and/or coding experience
• Strong knowledge of: 1) Disease processes and clinical indicators, 2) ICD-10-CM/PCS coding concepts, 3) DRG, SOI/ROM, and/or HCC methodologies, 4) Excellent written and verbal communication skills, 5) Proficiency with electronic health records (EHRs)

Preferred Education/Certification (Indicate preferred education or degree required.)

• CDI certification (CCDS, CCDS-O, CDIP)
• Coding certification (CCS, CPC, RHIA, RHIT)
• Prior experience in acute care, outpatient CDI, or risk adjustment
• Familiarity with ACDIS and AHIMA CDI guidelines

Minimum Work Experience and Qualifications (Indicate minimum years of job experience, skills or abilities required for the job.)

• Clinical critical thinking and analytical skills
• Professional provider communication and conflict resolution
• Attention to detail and accuracy
• Ability to work independently and collaboratively
• Strong organizational and time-management skills

Preferred Work Experience and Qualifications (Indicate preferred years of job experience, skills or abilities required for the job.)

• N/A

Required Licensure, Certification, Registration or Designation (List any licensure or certification required and specify name of agency.)

• Current Los Angeles County Fire Card (or must be obtained within 30 days of hire)
• Assault Response Competency (ARC) required (within 30 days of hire)