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Clinical Documentation Improvement Specialist

Universal Health Services

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Universal Health Services
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Job Details

Clinical Documentation Improvement Specialist

Job Code:  225030
Facility: Southwest Healthcare System
Location: MURRIETA, CA US Western
Region: Western
Travel Involved: None
Job Type: Full Time
Job Level:  Experienced (Non-Manager)
Minimum Education Required: Associate Degree 
Category: Support
FTE: 1.0
Position Summary:

Voted Top Workplace in 2016!

Inland Valley Medical Center

A 122 bed acute care hospital which features the regions only Level II Trauma Unit and is the county-designated Paramedical Base station and Southwest Riverside County’s only Center of Excellence in Weight Loss Surgery.

Rancho Springs Medical Center

A 120 bed acute care hospital which includes the region’s largest birthing center along with the area’s only NICU in combination with Rady Children’s Hospital and the region’s  first da Vinci Robotic Surgical Program.

Join our Team of Professionals as a Clinical Documentation Improvement Specialist.



Responsible for improving the overall quality and completeness of clinical documentation.  Promotes a partnership between the concurrent clinical reviews, medical record coders, and physicians to improve documentation and reimbursement for SWHCS.  Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement.  Responsible for reviewing medical records to identify payer population as documented upon admission and throughout the hospitalization.  Analyzes status of patient, current treatment plan, past medical history and identified possible gaps in physician documentation.  Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality.  Educates all members of the healthcare team on an ongoing basis.

Qualifications to include:

Ø  Knowledge of care delivery documentation systems and related medical record documents.

Ø  Knowledge of age-specific needs and the elements of disease processes and related procedures.

Ø  Strong broad based clinical knowledge and understanding of anatomy and pathology/physiology of disease processes.

Ø  Good command of the English language with excellent written and verbal communication skills at all levels.

Ø  Excellent critical thinking skills required.

Ø  Demonstrate good nurse-physician relationships in the past and has the ability to maintain those going forward.

Ø  Working knowledge of current ICD-9-CM coding guidelines, with working knowledge of Medicare reimbursement system preferred.

Ø  Working knowledge of inpatient admission criteria.

Ø  Ability to work independently in a time-oriented environment.

Ø  Computer literacy and familiarity with the operation of basic office equipment.  Proficiency in the use of computers and software applications, which includes Invision, eHIM Soarian, 3M HDM, CDIS program.  Knowledge in Microsoft Office applications such as: Excel, Work, Outlook and Power Point.

Ø  Assertive personality traits to facilitate ongoing physician communication.

Ø  Ability to stand and walk for periods of time is required in the performance of job responsibilities.  Must be able to travel between facilities as needed.

Ø  Detailed oriented, ability to collect, trend and report data.

Ø  Excellent organizational skills required.

Ø  Ability to perform under pressure, meet frequent deadlines and tight schedules.





Ø  Minimum of five years recent clinical experience in acute care setting.  Critical care or Medical/Surgical preferred or three to five years experience with inpatient coding and DRG guidelines.



Holds an AS degree in Nursing from an accredited two-year program in a college or a BS degree in Nursing  from an accredited four-year program in a college/university. BSN preferred.



Ø  Holds a current Registered Nurse (RN) license from the State of California.

Ø  Preferred - Holds a current Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) These certifications are accredited through the American Health Information Management Association and Association of Clinical Documentation Improvement Specialists.


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