Clinical Doc Improve Spec 1

Community Health System

Fresno, CA, United States4w ago

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Key details

Location
Fresno, CA, United States
Work style
Onsite
Level
Senior
Experience
5–8 yrs
Function
Healthcare
Focus area
other
Posted
4w ago

Skills

clinical documentationmedical records

About the role

Overview

Opportunities for you!

  • Consecutively recognized as a top employer by Forbes, and in 2025 by Newsweek
  • Free Continuing Education and certification
  • Tuition reimbursement, education programs and scholarships
  • Vacation time starts building on Day 1, and builds with your seniority
  • Free money toward retirement with a 403(b) and matching contributions

Commitment to diversity and inclusion is a cornerstone of our culture at Community. All are welcome as valued members of our community.

We know that our ability to provide the highest level of care is through taking care of our incredible teams. Learn more on our Benefits page.

Responsibilities

The Clinical Documentation Improvement (CDI) Specialist 1 conducts reviews of patient medical records to ensure documentation is accurate and up-to-date. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Educates members of the patient care team regarding documentation guidelines.

Qualifications

Education

  • Bachelor's Degree in Nursing preferred

One of the following is required:

  • Associate's Degree or higher in Nursing

  • Doctor of Medicine (MD) from an accredited medical school

  • Doctor of Osteopathic Medicine (DO) from an accredited medical school

  • Medical Degree from a foreign medical school with successful completion of the USMLE Step 1 and Step 2 Exams

Experience

  • 5 years of clinical experience in an acute hospital setting with demonstrated expertise in Med/Surg, OB, Trauma, ICU, and/or CCU required

  • Prior coding or Clinical Documentation Improvement (CDI) program experience preferred

Licenses and Certifications

  • RN - Current and valid Registered Nurse license to work within the state of California (if education is in Nursing) required

  • ECFMG - Educational Commission for Foreign Medical Graduates (if education is from a foreign medical school) required

One of the following is preferred:

  • CCDS - Certified Clinical Documentation Specialist

  • CDIP - Certified Documentation Improvement Practitioner

Disclaimers

• Pay ranges listed are an estimate and subject to change.• If any bonuses are noted, they are only applicable to external hires meeting criteria.

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