Salary : $103,983.50 - $140,924.44 Annually
Location : Riverside
Job Type: Regular
Job Number: 26-13407-02 AL
Department: RUHS-Medical Center
Opening Date: 10/22/2026
Closing Date: 11/1/2026 5:00 PM Pacific
Inpatient Clinical Documentation Improvement (CDI) Specialist for the Health Information Management division. CDI Specialists review medical records to ensure documentation is complete, clear, accurate, and aligned with coding and documentation standards. This role focuses on concurrent reviews during a patient's hospital stay to confirm documentation reflects the services provided and the patient's severity of illness.
The CDI Specialist is experienced in clinical documentation review and capable of improving the accuracy, specificity, and completeness of patient-care documentation. Ideal candidates will also have a strong understanding of PSI and HAC metrics, ensuring documentation and coding accurately reflect patient acuity and quality outcomes in an acute care setting. The role serves as a subject matter expert on coding rules and regulations, writes physician queries when clarification is needed, and provides guidance to physicians, clinicians, and coders on documentation requirements. This position requires deep knowledge of medical records, terminology, diagnoses, treatment plans, and clinical protocols.
Training will follow a 5/40, Monday-Friday onsite schedule, typically 8:00 a.m. to 4:30 p.m., with some flexibility in start times. After the employee demonstrates full competency in RUHS CDI processes and meets productivity expectations, they may transition to a hybrid schedule. Training duration will vary based on proficiency and performance
EXAMPLES OF ESSENTIAL DUTIES• Complete admission reviews of patients' records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.
• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and conduct follow-up reviews as necessary.
• Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.
• Communicate with and serve as a resource for physicians, nurses and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity.
• Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (i.e., ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by the Office of State Wide Hospital Planning and Development (OSHPD) and the Medical Audit Committee or individual physicians for various studies, statistical indexing and preparation of summary reports to various regulatory agencies.
• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements.
MINIMUM QUALIFICATIONS OPTION IEducation: Graduation from an accredited college or university with a bachelor's degree in nursing.
Experience: Three years as a registered nurse in an acute care hospital. One year of
inpatientCDI experience strongly preferred.
License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.
Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.
OPTION IIEducation: Graduation from an accredited college or university with a bachelor's degree in health information management, health information technology or a related field to the assignment. (Additional qualifying experience may substitute for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education).
Experience: Four years of professional coding and abstracting medical records in a healthcare setting. One year of
inpatientCDI experience strongly preferred.
Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association.
OPTION IIIEducation: Completion of Doctor of Medicine degree.
Experience: One year of clinical documentation improvement experience in a healthcare setting. One year of
inpatient CDI experience strongly preferred.
Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in Clinical Documentation preferred.
ALL OPTIONSKnowledge of: Coding, abstracting and terminology systems such as International Classification of Diseases, Clinically Modified (ICD-10) and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.
Ability to: Analyze and interpret the technical elements of a medical chart; analyze, code and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; effective communication skills.
SUPPLEMENTAL INFORMATION This recruitment is open to all applicants.
For additional information about this recruitment contact:Angela Levinson
951-955-5562 or alevinson@rivco.org
APPLICATION INFORMATIONVeteran's Preference The County has a Veterans Preference Policy applicable to new hires. To qualify, attach the required documents to your job application. Documents include a copy of your (or your spouse's) Member-4 Form DD-214 indicating dates of service. For spousal preference, and as applicable, the following documents: a copy of your marriage certificate, spouse's death certificate, a letter of spouse's disability and/or letter of service-related death (if available) from the U.S. Veteran's Administration. For privacy reasons, it is recommended that you remove your social security information from the document(s). A Human Resources Representative will review the materials and determine if you qualify for veterans' preference. For complete details and documentation requirements, please review the Veterans Preference Policy, C-3 here:
Schedule, Overtime, Standby/On-Call, and Travel ObligationsThe County of Riverside offers a variety of alternative work schedules, dependent upon department operations and needs. Certain assignments may involve overtime, standby/on-call shifts, and/or travel; however, scheduling, shift assignments, overtime work, standby/on-call duty, and travel obligations are subject to management approval, operational needs, and/or may be modified or discontinued at any time. Applicants should contact the assigned recruiter for additional information regarding the schedule, overtime and standby/on-call expectations, and travel obligations.
Proof of Education If using education to qualify or when requested by the recruiter, upload a copy of any license(s), official/unofficial transcript(s), degrees, and/or related employment documents to your NeoGov account at the time of application and before the closing date. Official or unofficial transcripts will be accepted.
If your education was completed outside of the United States, you will need to provide a copy of your Foreign Education Equivalency evaluation from a member of the National Association of Credential Evaluation Services () or Association of International Credential Evaluators, Inc. ().
Work Authorization RequirementApplicants must be legally authorized to work in the United States at the time of application. The County of Riverside does not participate in visa sponsorship programs, including H1-B visas, and will not provide sponsorship for any employment-based visas.
BENEFIT PROGRAM: SEI
MEDICAL/DENTAL/VISION INSURANCE: A choice of different medical, dental and visions plan are available to elect. The County provides a Flexible Benefit Credit contribution as governed by the applicable SEIU Memorandum of Understanding to contribute towards the cost of these plans.
Note: Employees on assignment through the Temporary Assignment Program (TAP) receive different benefits. See the list
MISCELLANEOUS RETIREMENT: County of Riverside has three retirement Tiers through the California Public Employees' Retirement System (CalPERS).
- Tier I (Classic Member - Formula 3% @ 60): Applicable to current and former County of Riverside local miscellaneous employees hired prior to 08/24/2012 and did not withdraw CalPERS contributions. The employee contribution is eight (8%) percent.
- Tier II (Classic Member - Formula
