Job Description

CDI Specialist - Los Angeles



Date Posted:


Employment Type:



Delaney Fruin

Recruiter Email:

Job ID:

JN -032022-14952

Job Description

AViD Technical Resources is seeking a California Registered Nurse to be their Clinical Documentation Improvement (CDI) Specialist for their Health Care client in Los Angeles

•    California Registered Nurse (or equivalent) preferred
•   3+ Years of clinical hospital experience; or equivalent of education and experience in case management, utilization management or prior clinical documentation review experience
•    Recent experience in care management, quality utilization or coding
•    Working knowledge of laws, rules and regulations regarding appropriate clinical documentation for government programs as Medicare and MediCal.
•    Leadership, supervisory, and training skills.
•    Self-directed, assertive and excellent critical thinking skills, knowledge of documentation systems and related medical record documents.
•    Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills.
•    Ability to work effectively and collaboratively with physician/staff and interdisciplinary teams.
•    Basic working knowledge of a large University teaching hospital; its purpose and functions.
•    Basic computer skills.

*Candidates must be CA RN and send copy of License upon submittal*
*Must list scheduled time off upon submittal; cannot be changed later* 
*Must be able to work weekends (OT eligible)* 

Job Duties & Responsibilities:

Medical Record Review
  • Completes review of medical record for identified patients in the required timeframes.
  • Identifies and creates documentation queries to be sent to physicians, residents and mid-levels.
  • Communicates with physicians face to face or via CDI query forms to clarify information, obtain needed documentation and educate for appropriate DRG based on severity of illness and risk of mortality.
  • Follows up on all queries sent and maintains timely review of medical records while patient remains an inpatient. 
  • Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, and impact of procedures on DRG; and is able to impart this knowledge to physicians, residents, mid-levels, nurses and other health team members.
Resource Management and Utilization
  • Applies appropriate documentation to a computer database (Care Connect and CDR2) to identify the most appropriate diagnosis and CC’s to accurately reflect the severity of illness.
  • Confers with physicians, residents, nurses and other clinical caregivers to explain the importance of clear and concise documentation.
  • Continuously confers with hospital coding staff to ensure appropriate DRG and completeness of supporting documentation.
  • Continually assesses and improves physician, case manager, nurse and other education for the health team to promote complete and accurate clinical documentation and correct negative trends.
  • Conducts seminars and presentations to hospital staff, as needed, to educate on specific departmental and hospital-wide topics related to clinical documentation and quality.
Tracking and Reporting Functions
  • Maintains accurate data in the tracking database
  • Provides reports and identifies trends as needed
  • Provides required/requested information, inappropriate resource utilization, statistical data or reports for Hospital Administration, Hospital Utilization Committee or Medical Staff.
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