CHA Hollywood Presbyterian Medical Center
Clinical Documentation Improvement Specialist Full Time Days
The Clinical Documentation Improvement (CDI) Specialist ensures the accuracy, completeness, and clinical validity of medical record documentation. The role works with providers, coders, quality, and compliance teams to support accurate coding and reimbursement, regulatory compliance, and documentation that reflects severity of illness, risk of mortality, and quality outcomes.
Key Responsibilities
- • 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
- • Ensure documentation supports appropriate secondary diagnoses (CC/MCCs, HCCs)
- • Ensure documentation supports appropriate procedures and POA status
- • Ensure documentation supports appropriate Severity of Illness (SOI) and Risk of Mortality (ROM)
- • 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
- • 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
- • 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
- • Monitor and report CDI performance metrics, including query rates and response times
- • Monitor and report CDI performance metrics, including documentation improvement trends
- • Performs all other duties as assigned or required
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 disease processes and clinical indicators
- • Strong knowledge of ICD-10-CM/PCS coding concepts
- • Strong knowledge of DRG, SOI/ROM, and/or HCC methodologies
- • Excellent written and verbal communication skills
- • Proficiency with electronic health records (EHRs)
- • 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
- • Current Los Angeles County Fire Card (required within 30 days of employment)
- • Assault Response Competency (ARC) (required within 30 days of employment)
Preferred
- • 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
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
Performs all other duties as assigned or required.
Minimum Education/Certification (Indicate Minimum Education Or Degree Required.)
Shift: Days
Hours: 8hrs
Weekly/Bi-Weekly Hours: 40hrs/80hrs
FTE: 1.0
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)
- 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
- 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
- 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
- Monitor and report CDI performance metrics, including:
- Query rates and response times
- Documentation improvement trends
Performs all other duties as assigned or required.
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)
- 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
- 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
- N/A
- Current Los Angeles County Fire Card (required within 30 days of employment)
- Assault Response Competency (ARC) (required within 30 days of employment)
Shift: Days
Hours: 8hrs
Weekly/Bi-Weekly Hours: 40hrs/80hrs
FTE: 1.0
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