Clinical Documentation Specialist

May 23, 2025

Pomona Valley Hospital Medical Center

CDI | Clinical Documentation Integrity Specialist, Critical Care, Neonatal, OB/GYN, Registered Nurse | RN, Trauma
Remote

Employment Type:

Regular | Perm Employee

Schedule:

Full-time

Remote Status:

Remote

License:

CA

Pomona Valley Hospital Medical Center

CDI | Clinical Documentation Integrity Specialist, Critical Care, Neonatal, OB/GYN, Registered Nurse | RN, Trauma
Remote

Employment Type:

Regular | Perm Employee

Schedule:

Full-time

Remote Status:

Remote

License:

CA

FULLY REMOTE POSITION

Job Summary: The Clinical Documentation Integrity Specialist (CDIS) is responsible for facilitating the improvement in the
quality and completeness of medical record documentation. The CDIS obtains appropriate clinical documentation through extensive interaction with physicians, multi-disciplinary team, and Health Information Management Associates to ensure that the medical record accurately reflects the patient’s clinical condition and treatment rendered resulting in accurate reimbursement and outcomes reporting. Maintains current knowledge and understanding of ICD-10 CM & PCS coding, DRG systems and AHIMA Coding Clinic & Coding
guidelines. May perform other duties as assigned.

Required qualifications: Current unrestricted California RN license. Graduate of accredited School of Nursing with Associates degree. Three years acute hospital/clinical experience and minimum one year of Clinical Documentation Specialist experience. Candidate must have technical knowledge of ICD-10, MS-DRG and APR-DRG assignment and prospective payment methodologies. In addition, strong knowledge of clinical documentation guidelines required. Must be detail oriented, have the ability to work independently, exercise good judgment and be resourceful. Position requires strong interpersonal skills to work with key stakeholders, physicians and/or clients and staff. Position requires strong organizational and time management skills and ability to teach and present educational topics. Data entry and typing required.

Preferred Qualifications: Bachelor’s degree. CCDS, CDIP, or CCS. Adult inpatient, NICU, OB and Trauma experience is a plus both from clinical and CDI perspective.

Salary range: $64.75 – $95.72

Location: Pomona Valley Hospital Medical Center · CDI & DENIAL PREVENTION
Schedule: Full time, 1 – Days, 8