Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community. 

Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs.

Position Summary:

The Clinical Documentation Improvement Specialist (CDI) performs concurrent review of medical records.  Issues concurrent physician inquiries, and interacts with the medical staff and other healthcare staff in an effort to assure complete and accurate documentation of the patient's clinical picture and the treatment provided.   The CDI acts as a liaison between case management, coding professionals and the medical staff.  The CDI is responsible for improving overall quality and completeness of clinical documentation. 

Major Position Responsibilities:

The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization.

• Clinical Documentation Improvement:
  • Review medical records for completeness and accuracy, identifying any missing or unclear information regarding diagnoses, treatments, & care plans.
  • Analyze documentation to clarify and validate diagnoses, ensuring accurate Diagnostic Related Group (DRG) assignment, severity of illness, risk of mortality, and case mix data.
  • Collaborate with physicians, nurses, coders, and other healthcare staff to address documentation gaps and improve overall record quality.
  • Query providers to clarify inconsistent or incomplete documentation in an ethical, compliant manner.
  • Facilitate accurate reimbursement by tracking insurance queries and ensuring providers receive appropriate compensation for their services.
  • Develop CDI policies and procedures around query processes, education, training, and performance measurements.
  • Report and analyze data for quality improvement purposes, preparing feedback for team members and leadership.
  • Completes concurrent review of assigned population; achieving a high accuracy rate.
• Safety and Compliance:
  • Maintain a safe, clean working environment, adhering to infection control and hospital policies.
  • Monitor and audit records to ensure regulatory compliance (including HIPAA), prevent fraud, and avoid unnecessary insurance denials.
  • Comply with regulatory standards (e.g., The Joint Commission, OSHA).
  • Identify and report safety concerns
• Professional Development and Leadership:
  • Provide education to clinical staff on proper documentation practices and coding criteria, including ongoing training and development.
  • Participate in program meetings, staff education, development activities, and in-service opportunities.
  • Analyze trends and data to recommend process improvements for accurate clinical documentation.
  • Develop and implement formal and informal education plans for physicians, nurses and clinical staff to improve accuracy in clinical documentation.
  • Provide mentorship to New Graduate Nurses and students, supporting their professional development.

 Qualifications:

• Minimum of five (5) years Registered Nurse experience, with three (3) years as a Registered Nurse in utilization management or six (6) months as a Registered Nurse in Clinical Documentation Improvement, required.

Competencies:

• Technical Skills:
  • Proficient computer skills, including Word.
  • Knowledge and understanding of various payer types
  • Knowledge of ICD-10-CM coding conventions, risk adjustment models, and Hierarchical Condition Category Coding (HCC).
  • Expert knowledge of clinical care and coding guidelines.
  • Experience with referral management system, preferred
• Critical Thinking:
  • Detail-oriented approach to reviewing and improving medical documentation
  • Strong prioritization skills
  • Self-motivated, independent thinker
• Communication:
  • Strong communication, teamwork, analytical, and leadership skills.
  • Ability to analyze, educate, and communicate effectively with diverse clinical teams.

Education: 

• Associate Degree in Nursing, required.  

Licenses:

• Current California Registered Nurse, required.

Certifications:

• Current CDI certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) within 18 months of hire or transfer, required.
• Registered Health Information Administrator (RHIA) or Registered Health Information Technologist (RHIT) or Certified Coding Specialist (CCS), preferred.
• Accredited Case Manager (ACM) or Certified Case Manager (CCM), or equivalent certification, preferred.

Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work. 

*Salary/Hourly wage range for this position is posted.  Actual pay will be determined based on verified experience as well as internal equity.

TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.