Job Description

Monterey, CA

Full Time

Work Hours: 7-3:30/M-F


Clinical Documentation Specialist


Position Highlights

·         Excellent Pay and Generous Benefits including a Pension and Scholarship Reimbursement

·         Excellent Team Orientated Culture

·         Free Gym for Employees onsite

·         Employee Commissary 

·         "Best Place to work in Monterey County" 9 years in a row!


Position Summary

The CDI Specialist is responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure that appropriate reimbursement is received for the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete and accurate. Will facilitate appropriate clinical documentation to ensure that level of services and acuity of accurately reflected in the medical record. Demonstrates knowledge of documentation requirements and guidelines in accordance with Coding Clinic and improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines. Will be responsible for educating internal staff on clinical documentation guidelines and conducts follow up reviews of clinical documentation to ensure points clarified with the physician have been recorded in the patient's record. Reviews clinical issues with the coding staff to assign a working DRG.


Experience/Skill Set:

·       A minimum of two years experience in nursing or other clinical area, coding, process improvement or utilization review/case management in an acute care facility required

·        Effective interpersonal skills in order to interact effectively with all levels of hospital personnel required

·        Organization and prioritization skills needed

·        Effective written and verbal communication skills needed

·        Analytical skills required

·        Proficient computer skills required

·        Previous experience in clinical documentation improvement program preferred



·         As need to obtain proper licensure.



·         RN, LVN, and/or RHIA, RHIT or CCS or combination there of


Equal Opportunity Employer

Application Instructions

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