Job Description

Position Name: Clinical Documentation Specialist

Category: Support Department Case Management

Management: No

Schedule: Full Time 8:00 AM - 4:30 PM

Reports To: Director of Case Management


  • Performs on-site medical record reviews, by examining and assessing all patient documentation to ensure that all information including the illness diagnosis is accurate and facilitates improvement in the overall quality, completeness and accuracy of medical record documentation.
  • This position interacts with physicians, Health Information Management (HIM) coding staff and other members of the health care team to ensure the accuracy and completeness of clinical documentation that supports resource utilization, length of stay and patient outcomes. On an ongoing basis, educate all members of the patient care team and participates in the development of educational tools and programs for the health care team.


  • Current CA RN License. Minimum of five (5) years RN clinical experience or Foreign Medical Graduate (FMG). CDI credential required within two (2) years of hire (CCDS, CDIP).
  • Must be comfortable in communicating and working closely with Physicians. Critical thinking skills to problem solve on critical issues. Strong understanding of Microsoft Work, Excel, and other Word related software.
  • Familiarity with CMS and UR review.