Clinical Documentation Specialist CDI in California

Immediate need for a talented Clinical Documentation Specialist CDI in California. This is a 06+months contract opportunity with long-term potential and is located in California(Remote). Please review the job description below and contact me ASAP if you are interested. Job ID: 26-17797 Pay Range: $45/hr - $50/hour. Traveler benefits as per agency package. (Benefits vary by vendor and assignment). Key Responsibilities:

• SPerform concurrent and retrospective reviews of inpatient medical records to ensure complete and accurate clinical documentation.
• Identify opportunities to improve documentation related to severity of illness (SOI), risk of mortality (ROM), quality indicators, and reimbursement.
• Develop and issue compliant physician queries following AHIMA, ACDIS, and organizational guidelines.
• Collaborate with physicians, coding professionals, case management, utilization review, and quality teams to improve documentation accuracy.
• Validate principal diagnoses, secondary diagnoses, CC/MCC capture, MS-DRG assignments, and clinical indicators.
• Support denial prevention and appeals by providing clinical validation and documentation support.
• Monitor documentation trends and identify opportunities for physician education.
• Participate in interdisciplinary rounds and CDI team meetings.
• Analyze clinical documentation data and provide recommendations for process improvement.
• Assist in the development and delivery of provider education programs related to documentation best practices.
• Maintain productivity and quality standards while managing a high-volume review workload.
• Ensure compliance with CMS regulations, Coding Clinic guidance, and organizational policies

Key Requirements and Technology Experience:

• Associate Degree in Nursing (ADN), BSN, MSN, Doctor of Medicine (MD), or Foreign Medical Graduate.
• Active RN License OR Medical Degree (Foreign Medical Graduates with post-graduate clinical patient care experience will be considered).
• Minimum 4 years of clinical nursing or physician experience in an acute care setting.
• Minimum 2 years of Clinical Documentation Integrity (CDI) experience.
• Experience reviewing inpatient medical records and assigning DRGs.
• Strong knowledge of:
• ICD-10-CM
• MS-DRGs
• Clinical validation
• Severity of Illness (SOI)
• Risk of Mortality (ROM)
• Documentation improvement methodologies
• Experience writing compliant physician queries.
• Strong analytical, communication, and critical thinking skills.
• Ability to work independently in a fully remote environment.
• Preferred Qualifications
• BSN, MSN, MD, or higher clinical degree.
• CCDS, CDIP, CCS, CPC, RHIA, or RHIT certification.
• Experience with 3M CDI and coding applications.
• ICU, Critical Care, Emergency Department, Hospitalist, Case Management, Utilization Review, or CDI experience.

Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration. Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. By applying to our jobs you agree to receive calls, AI-generated calls, text messages, or emails from Pyramid Consulting, Inc. and its affiliates, and contracted partners. Frequency varies for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You can reply STOP to cancel and HELP for help. You can access our privacy policy here. Apply tot his job Apply To this Job