Clinical Documentation Improvement Specialist

Clinical Documentation Improvement Specialist

Salary

$103,983.50 - $140,924.44 Annually

Location

Riverside

Job Type

Regular

Job Number

26-13407-02 AL

Department

RUHS-Medical Center

Opening Date

10/22/2026

Closing Date

11/1/2026 5:00 PM Pacific

• Description
• Benefits
• Questions

For questions regarding this position, please contact the Recruiter listed in the Supplemental Information section.

ABOUT THE POSITION

Riverside University Health System - Medical Center is seeking an Inpatient Clinical Documentation Improvement (CDI) Specialist for the Health Information Management division. CDI Specialists review medical records to ensure documentation is complete, clear, accurate, and aligned with coding and documentation standards. This role focuses on concurrent reviews during a patient's hospital stay to confirm documentation reflects the services provided and the patient's severity of illness.

The CDI Specialist is experienced in clinical documentation review and capable of improving the accuracy, specificity, and completeness of patient-care documentation. Ideal candidates will also have a strong understanding of PSI and HAC metrics, ensuring documentation and coding accurately reflect patient acuity and quality outcomes in an acute care setting. The role serves as a subject matter expert on coding rules and regulations, writes physician queries when clarification is needed, and provides guidance to physicians, clinicians, and coders on documentation requirements. This position requires deep knowledge of medical records, terminology, diagnoses, treatment plans, and clinical protocols.

Training will follow a 5/40, Monday-Friday onsite schedule, typically 8:00 a.m. to 4:30 p.m., with some flexibility in start times. After the employee demonstrates full competency in RUHS CDI processes and meets productivity expectations, they may transition to a hybrid schedule. Training duration will vary based on proficiency and performance

Meet the Team!

Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and is the only Pediatric ICU in the region. Can you see yourself here? For more information on RUHS-Medical Center, please visit ruhealth.org

EXAMPLES OF ESSENTIAL DUTIES

• Complete admission reviews of patients records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.
• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and conduct follow-up reviews as necessary.
• Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.
• Communicate with and serve as a resource for physicians, nurses and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.
• Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (i.e., ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by the Office of State Wide Hospital Planning and Development (OSHPD) and the Medical Audit Committee or individual physicians for various studies, statistical indexing and preparation of summary reports to various regulatory agencies.
• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.

MINIMUM QUALIFICATIONS

OPTION I

Education: Graduation from an accredited college or university with a bachelors degree in nursing.

Experience: Three years as a registered nurse in an acute care hospital. One year of inpatient CDI experience strongly preferred.

License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.

Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.

OPTION II

Education: Graduation from an accredited college or university with a bachelors degree in health information management, health information technology or a related field to the assignment. (Additional qualifying experience may substitute for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education).

Experience: Four years of professional coding and abstracting medical records in a healthcare setting. One year of inpatient CDI experience strongly preferred.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association.

OPTION III

Education: Completion of Doctor of Medicine degree.

Experience: One year of clinical documentation improvement experience in a healthcare setting. One year of inpatient CDI experience strongly preferred.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in Clinical Documentation preferred.

ALL OPTIONS

Knowledge of: Coding, abstracting and terminology systems such as International Classification of Diseases, Clinically Modified (ICD-10) and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.

Ability to: Analyze and interpret the technical elements of a medical chart; analyze, code and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; effective communication skills.

SUPPLEMENTAL INFORMATION

This recruitment is open to all applicants.

For additional information about this recruitment contact:

Angela Levinson

951-955-5562 or alevinson@rivco.org

____

APPLICATION INFORMATION

Veterans Preference

The County has a Veterans Preference Policy applicable to new hires. To qualify, attach the required documents to your job application. Documents include a copy of your (or your spouses) Member-4 Form DD-214 indicating dates of service. For spousal preference, and as applicable, the following documents: a copy of your marriage certificate, spouses death certificate, a letter of spouses disability and/or letter of service-related death (if available) from the U.S. Veterans Administration. For privacy reasons, it is recommended that you remove your social security information from the document(s). A Human Resources Representative will review the materials and determine if you qualify for veterans preference. For complete details and documentation requirements, please review the Veterans Preference Policy, C-3 here: https://rivcocob.org/board-policies

Reasonable Accommodations

The County of Riverside is committed to providing reasonable accommodation to applicants as required by the Americans with Disabilities Act (ADA) and Fair Employment and Housing Act (FEHA). Qualified individuals with disabilities who need a reasonable accommodation during the application or selection process should contact the recruiter for the position noted above. For additional information and/or to obtain the appropriate form for requesting a reasonable accommodation, please visit the Disability Access Office web page located at: https://rc-hr.com/disability

Schedule, Overtime, Standby/On-Call, and Travel Obligations

The County of Riverside offers a variety of alternative work schedules, dependent upon department operations and needs. Certain assignments may involve overtime, standby/on-call shifts, and/or travel; however, scheduling, shift assignments, overtime work, standby/on-call duty, and travel obligations are subject to management approval, operational needs, and/or may be modified or discontinued at any time. Applicants should contact the assigned recruiter for additional information regarding the schedule, overtime and standby/on-call expectations, and travel obligations.

Proof of Education

If using education to qualify or when requested by the recruiter, upload a copy of any license(s), official/unofficial transcript(s), degrees, and/or related employment documents to your NeoGov account at the time of application and before the closing date. Official or unofficial transcripts will be accepted.

If your education was completed outside of the United States, you will need to provide a copy of your Foreign Education Equivalency evaluation from a member of the National Association of Credential Evaluation Services (NACES) or Association of International Credential Evaluators, Inc. (AICE).

Work Authorization Requirement

Applicants must be legally authorized to work in the United States at the time of application. The County of Riverside does not participate in visa sponsorship programs, including H1-B visas, and will not provide sponsorship for any employment-based visas.

Equal Opportunity Employer

The County of Riverside is an Equal Opportunity Employer. It is the policy of the County of Riverside to provide equal employment opportunities for all qualified persons. All applicants will be considered without regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender, gender identity, gender expression, marital status, ancestry, medical condition (cancer and genetic characteristics), genetic information, or denial of medical and family care leave, or any other non-job-related factors.

Pre-Employment

All employment offers are contingent upon successful completion of pre-employment requirements including a criminal background investigation, which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment). A pre-employment physical examination and background check may be required.

Probationary Period

As an Approved Local Merit System, all County of Riverside employees, except those serving "At Will," are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding, County Resolution, or Salary Ordinance. Temporary and Per Diem employees serve at the pleasure of the agency/department head.

General Information

Current County of Riverside and/or current employees of the hiring department may receive priority consideration. Qualified candidates may be considered for future County vacancies.

Job postings may close without notice based on application volume. Submit your complete application by the recruitment close date; no late applications are accepted. Ensure all relevant experience/education is reflected on your application/resume, as a failure to demonstrate position requirements may disqualify applicants. A description of job duties directly copied from the job classification or job posting will not be considered.

Please read and follow any special application instructions on this posting. Click the Apply link located on this page to submit your application. For additional instructions on the application process, examinations, Veterans preference, pre-employment accommodation or other employment questions, please refer to our web site, www.rc-hr.com.

If you are experiencing technical problems, you may contact the governmentjobs.com applicant support desk Monday through Friday, 6 am to 5 pm Pacific Time at support@governmentjobs.com or toll-free 1-855-524-5627.

BENEFIT PROGRAM: SEI

MEDICAL/DENTAL/VISION INSURANCE: A choice of different medical, dental and visions plan are available to elect. The County provides a Flexible Benefit Credit contribution as governed by the applicable SEIU Memorandum of Understanding to contribute towards the cost of these plans.

Note: Employees on assignment through the Temporary Assignment Program (TAP) receive different benefits. See the list here.

MISCELLANEOUS RETIREMENT: County of Riverside has three retirement Tiers through the California Public Employees Retirement System (CalPERS).

• Tier I (Classic Member - Formula 3% @ 60): Applicable to current and former County of Riverside local miscellaneous employees hired prior to 08/24/2012 and did not withdraw CalPERS contributions. The employee contribution is eight (8%) percent.
• Tier II (Classic Member - Formula 2% @ 60): Applicable to local miscellaneous employees 1) hired after 08/23/2012 through 12/31/2012; 2) Previously employed with another CalPERS contracting public agency or a reciprocal retirement system, with a break in service of less than six months between the separation date with the previous employer and the appointment date with the County of Riverside. The employee contribution is seven (7%) percent.
• Tier III (PEPRA New Member - Formula 2% @ 62): Applicable to CalPERS local miscellaneous new members hired on or after the implementation of the Public Employees Pension Reform Act of 2013 (PEPRA) which took effect January 1, 2013. Effective July 1, 2023 employee contributions are 7.25% and will increase to 7.75% effective July 1, 2024.

A new member is defined as any of the following:

• A new hire who enters CalPERS membership for the first time on or after January 1, 2013, and who has no prior membership in any California Public Retirement System.
• A new hire who enters CalPERS membership for the first time on or after January 1, 2013, and who was a member with another California Public Retirement System prior to that date, but who is not subject to reciprocity upon joining CalPERS.
• A member who first established CalPERS membership prior to January 1, 2013, and who is rehired by a different CalPERS agency after a break in service of greater than six (6) months.

CalPERS refers to all members that do not fit within the definition of a new member as "classic members".

Contribution rates are subject to change based on the County of Riverside annual actuarial valuation.

Note:

This summary is for general information purposes only. Additional questions regarding retirement formulas can be sent to retirement@rivco.org or by calling the Benefits Information Line at (951) 955-4981,

Option 2.

If you have prior service credit with another CalPERS agency or within agencies, please contact CalPERS at (888) 225-7377 to determine which retirement tier would be applicable to you. CalPERS is governed by the Public Employees Retirement Law. The Retirement Law is complex and subject to change. If theres any conflict between this summary and the law, the law will prevail over this summary.

DEFERRED COMPENSATION: Voluntary employee contribution with a choice between two 457 deferred compensation plan options.

VACATION ACCRUAL (Bi-Weekly Accrual):

0 < 3 year = 80 Hours (10 Days)

4 < 9 years = 120 Hours (15 Days)

10 or more years = 160 Hours (20 Days)

Maximum Vacation leave accumulation is 480 hours.

SICK LEAVE: Four (4) hours Sick Leave accrual per pay period with unlimited accrual.

HOLIDAYS: Normally 12 paid holidays per year.

BEREAVEMENT LEAVE: Allowed 5 days (3 days are County paid; 2 additional days can be taken from accrued Sick Leave balance).

BASIC LIFE INSURANCE: Equal to one times annual base salary not to exceed $50,000 of term life coverage. Premiums are paid by the County. Additional Supplemental Life plan is available for employee purchase.

DISABILITY:

Employees contribute to State Disability Insurance (SDI), which provides wage replacement benefits for individuals who are unable to work due to non-work-related illness, injury, or pregnancy. SDI also includes Paid Family Leave Benefits. The wage replacement rate is determined by current law, offering 60-70% of the wages earned during the SDI eligibility period.

Additionally, employees receive employer-paid Long-Term Disability Benefits, which cover 66.67% of pre-disability earnings, up to a maximum of $10,000 per month. There is a 365-day waiting period before these benefits become active. Employees may coordinate these benefits with other available leave balances to receive up to 100% of their regular pay.

POST RETIREMENT MEDICAL CONTRIBUTION: A monthly contribution is made by the County towards retiree health insurance offered through the County as governed by the applicable SEIU Memorandum of Understanding.

OTHER: There may be other benefit provisions as specified in the applicable Memorandum of Understanding. Please contact the recruiter listed on the job posting directly for more information.

01

Do you have a Bachelors degree in nursing and at least three years of Registered Nurse experience in an acute care hospital and hold a valid CA RN license?

• Yes
• No

02

What is the highest level of education you have completed from an accredited college or university with coursework in health information management, health information technology or in a field related to the assignment?

• No education or less than a year of education.
• One year but less than two years of education.
• Two years but less than three years of education, or completion of an Associates degree.
• Three years but less than four years of education.
• Four years of education, no bachelors degree.
• Bachelors degree.
• Masters degree.
• Doctorate.

03

Do you have a valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association.

• Yes
• No

04

How many years of experience do you have coding and abstracting medical records in a healthcare setting?

• None - less than one year of experience
• One year but less than two
• Two years but less than three.
• Three years but less than four.
• Four years but less than five.
• Five years but less than six.
• Six years but less than seven.
• Seven years but less than eight.
• Eight years or more experience coding and abstracting medical records.

05

Do you possess a Doctor of Medicine degree from the US or another country AND have at least one year of experience performing clinical documentation improvement in a healthcare setting?

• Yes
• No

06

Do you have experience utilizing EPIC and 3M Clinical Documentation Integrity Services

• Yes
• No

07

Do you have INPATIENT CDI experience?

• Yes
• No

Required Question

Employer County of Riverside

Address County Admin. Center P.O. Box 1569

4080 Lemon St., 7th floor

Riverside, California, 92502-1569

Phone Contact Recruiter for Job Information

Website http://www.rc-hr.com