Clinical Documentation Improvement Specialist Full Time Days

Job Summary

CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility founded in 1924, dedicated to serving the Hollywood community and surrounding areas. HPMC is part of a global healthcare network that includes hospitals, fertility centers, medical universities, and anti-aging centers.

Major Responsibilities/Essential Functions

• 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).

• Initiate compliant, clinically sound provider queries to clarify diagnoses and procedures.

• Track query response rates and outcomes.

• Provide real-time documentation feedback to providers.

• 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.

• 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.

• Support quality metrics, including mortality, complications, readmissions, and patient safety indicators.

• Aid 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.

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

Job Qualifications

• Minimum Education/Certification: 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:

  • Disease processes and clinical indicators
  • ICD-10-CM/PCS coding concepts
  • DRG, SOI/ROM, and/or HCC methodologies
  • Excellent written and verbal communication skills
  • Proficiency with electronic health records (EHRs)

• Preferred Education/Certification: CDI certification (CCDS, CCDS-O, CDIP), Coding certification (CCS, CPC, RHIA, RHIT)

• Preferred Experience: Prior experience in acute care, outpatient CDI, or risk adjustment, Familiarity with ACDIS and AHIMA CDI guidelines

• Minimum Work Experience and Qualifications: 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: N/A

• Required Licensure, Certification, Registration or Designation: Current Los Angeles County Fire Card (required within 30 days of employment), Assault Response Competency (ARC) (required within 30 days of employment)