Clinical Document Improvement Specialist (Orange, CA, 92868) | 07/22/26 Job Description Below mentioned is the job description for your reference:

Job Title:

Clinical Document Improvement Specialist

Location:

Orange, CA (92868)

Duration:

52

Weeks Shift Details:

Day Shift:

Monday - Friday (5x8 Hours)

Timing:

8:00 AM - 5:00 PM

Weekend Coverage Required

Work Mode:

Hybrid Position Summary:

The Clinical Documentation Specialist (CDI) is responsible for improving the overall quality, accuracy, and completeness of clinical documentation. This role involves detailed medical record review, collaboration with healthcare providers, and ensuring compliance with regulatory standards to support accurate coding, quality reporting, and reimbursement.

Key Responsibilities:

Review inpatient adult medical records across UCI Health facilities for accuracy, completeness, and compliance

Validate DRGs and identify documentation gaps

Initiate and manage physician queries to clarify documentation

Collaborate with physicians, coders, and clinical teams

Ensure documentation reflects severity of illness and risk of mortality

Educate providers on documentation best practices and guidelines

Analyze data and generate reports with actionable insights

Required Qualifications:

Strong clinical knowledge with ability to interpret complex medical documentation

Minimum 5+ years of clinical experience (RN or Physician)

Minimum 3+ years of CDI (Clinical Documentation Improvement) experience

Familiarity with Utilization Review criteria

Knowledge of Joint Commission and CMS regulations

Active CDI Certification (CCDS or CDIP)

Bachelor of Science in Nursing (BSN) or Medical School Graduate