Responsible for overseeing coding and clinical documentation integrity operations, auditing, reviewing internal and external audit results, and providing coding and clinical documentation integrity (CDI) education.
Responsibilities
Oversees coding and CDI operations, chart auditing, audits accuracy and staff feedback process
Develops, refines, implements and performs internal auditing as needed, verifying accuracy, completeness and precision of ICD-10 CM/PCS and CPT coding and clinical documentation integrity
Reviews and appeals all external DRG and clinical validation denials
Works closely with coding/CDI management team to report audit findings, trends, benchmarking data, staff remediation, re-education, and reassessment as needed
Plans and monitors staffing activities, including hiring, orienting, evaluating, disciplinary actions, productivity and quality monitoring, and staff training and education initiatives
Supervises daily operations of the Clinical Documentation Integrity program for Health Ministries within the region, overseeing staff, ensuring compliance, and driving quality improvement.
Compensation
(Hourly pay range: $47.2309-$70.8464)
Responsibilities
Supervise daily operations of the CDI team
Ensure compliance with program standards and policies
Coordinate performance improvement initiatives
Provide training and education to CDS staff
Manage scheduling and staffing assignments
Requirements
Bachelor’s Degree in Health Information Management, Healthcare related field or Nursing or equivalent
Nice to have: Certified Clinical Documentation Specialists (CCDS)
Nice to have: Certified Documentation Improvement Professional (CDIP)
Supports accurate, complete, and clinically specific provider documentation across the myPlace Health participant population.
Locations (2)
Compton, California, United States
Los Angeles, California, United States
Compensation
Base salary range: $71,700 to $105,000 per year
An annual employee bonus program
Responsibilities
Conduct prospective, concurrent, and retrospective reviews of medical records to identify documentation gaps, unsupported diagnoses, missed HCC opportunities, and clinically present conditions requiring provider assessment or clarification.
Apply clinical reasoning to synthesize information across EMR documentation, laboratory results, imaging reports, medications, specialist notes, and outside records to support accurate and clinically specific documentation.
Review longitudinal chart trends to identify disease progression, chronic condition indicators, and opportunities to improve documentation of participant complexity and severity of illness.
Clinical Documentation Spec 1 / HIM Clinical Document Mgmt
The Hospital of Central Connecticut · Posted May 15, 2026
Responsible for extensive record review, interaction with physicians, HIM coding professionals, nursing staff and other patient care givers to ensure accurate representation of patient severity of illness and quality of care.
Responsibilities
Provides extensive and accurate reviews of medical records within specified timelines
Recognizes opportunities for documentation improvement to support severity of illness and quality of care
Follows up on all cases especially those with clinical documentation clarifications/queries
Provides education to providers on responding to queries in the medical record and other CDI topics
Participates in Coding/CDI meetings and CDI H3W work group
Requirements
Associates Degree or equivalent
Nice to have: Registered Nurse with 8+ years acute care experience
Nice to have: 2+ years experience as a CDS
Nice to have: Certified Clinical Documentation Specialist (CCDS)
Nice to have: Certified Clinical Documentation Professional (CDIP)
The Clinical Documentation Integrity (CDI) Analyst is an exempt professional role responsible for independently applying advanced clinical knowledge, critical thinking, analytical skills, and documentation integrity expertise to improve the accuracy, completeness, specificity, and clinical validity of patient documentation.
Responsibilities
Perform comprehensive concurrent reviews of inpatient medical records to identify opportunities to improve documentation completeness, specificity, accuracy, and clinical validity.
Evaluate complex oncology, surgical oncology, hematologic malignancy, cellular therapy, transplant, critical care, and tertiary/quaternary care encounters to ensure accurate representation of patient acuity and treatment complexity.
Develop, issue, and manage compliant physician documentation queries in accordance with AHIMA, ACDIS, CMS, and organizational standards.
Partner with physicians, advanced practice providers, nursing, case management, quality teams, physician advisors, and coding professionals to strengthen documentation integrity and clinical representation.
Provide education on documentation requirements, clinical validation principles, SOI/ROM capture, mortality risk adjustment, quality reporting, and oncology-specific documentation.
Conduct comprehensive analysis of medical records, coded data, physician documentation, laboratory results, imaging findings, treatments, and patient outcomes to identify appeal opportunities.
Draft clear, persuasive, evidence‑based appeal letters using clinical indicators, coding guidelines, payer policies, Coding Clinic guidance, and CMS regulations.
Prepare first‑level and second‑level appeals and reconsideration requests for commercial, Medicare, Medicare Advantage, and Medicaid payers.
Defend the clinical validity of diagnoses commonly targeted by payers, including sepsis, acute respiratory failure, acute kidney injury, malnutrition, encephalopathy, and other MCC/CC conditions.
Requirements
Bachelor’s degree in nursing, Health Information Management, or a related healthcare field
Nice to have: Experience writing successful payer appeals
Formulate compliant verbal and written provider queries that present clinical evidence objectively and support provider clarification without directing clinical conclusions.
Partner directly with physicians, nurse practitioners, and clinical teams through chart-side discussion, consultation, and structured education to improve documentation quality and compliant CMS-HCC capture.
Requirements
Active, unrestricted RN or NP license in the state of California
Clinical Documentation Spec 1 / HIM Clinical Document MgmtThe Hospital of Central Connecticut · Farmington, US
CDI SpecialistCity of Hope · Remote, US