Job Description
Description We are looking for a Clinical Document Integrity (CDI) Specialist to join a healthcare organization in Sacramento, California on a Contract basis. In this role, you will strengthen the quality and completeness of clinical records through detailed chart review, collaboration with providers, and application of documentation and coding standards. This position plays an important part in supporting accurate clinical representation, compliant reporting, and reliable outcomes across assigned service areas.
Responsibilities:
• Conduct concurrent and retrospective reviews of inpatient and outpatient records to identify documentation gaps and improve the clarity of the clinical story.
• Evaluate charts early in the patient stay and continue follow-up reviews to confirm that clarification requests are addressed in the medical record.
• Apply established coding guidance, reimbursement rules, and regulatory standards to support accurate capture of diagnoses, procedure...
Responsibilities:
• Conduct concurrent and retrospective reviews of inpatient and outpatient records to identify documentation gaps and improve the clarity of the clinical story.
• Evaluate charts early in the patient stay and continue follow-up reviews to confirm that clarification requests are addressed in the medical record.
• Apply established coding guidance, reimbursement rules, and regulatory standards to support accurate capture of diagnoses, procedure...