Clinical Documentation Specialist*

The Job

Arrowhead Regional Medical Center (ARMC) is looking for Clinical Documentation Specialists* to perform chart review, analyze documentation, clinical conditions, and treatments required for an accurate representation of severity of illness. This position is responsible for identifying the expected risk of mortality and complexity of care for a patient's medical record in support of quality patient care and a healthy revenue cycle.

Clinical Documentation Improvement (CDI) is the process of reviewing medical record documentation for completeness, specifics, and accuracy, reviewing disease process, diagnostic findings, and what the documentation might be missing. A Clinical Documentation Specialist* manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness. In addition, Clinical Documentation Specialists* educate physicians on the importance of supplying the proper information needed for correct documentation.

*Official Job Title: Clinical Documentation Improvement Nurse. For more detailed information, refer to the Clinical Documentation Improvement Nurse job description.

HEALTH BENEFITS

PAID TIME OFF

RETIREMENT PERKS

• Medical & Dental: Family Coverage
• Vision: Employee Coverage
• Premium subsidies to offset health costs
• Flexible Spending Account: Pre-tax account for qualified healthcare expenses

• Up to 4 weeks accruable vacation with cash-out option
• 11 days accruable sick leave
• 15 paid holidays
• Perfect Attendance Leave
• Flexible work schedules (in some departments)

• Generous pension
• Retirement reciprocity may be available!
• 457(b) Deferred Compensation
• Retirement Medical Trust (RMT)

DCAP Account - County Paid Life Insurance - AD&D Insurance - 529 Savings Plan - Short & Long-Term Disability
Wellness Program - Commuter Services - Employee Discounts - Annual Tuition Reimbursement

For additional benefits details, please refer to our online benefits flyer here:
https://hr.sbcounty.gov/wp-content/uploads/sites/39/Documents/Benefits/BBOUs/2024-25/BbOU-Nurse.pdf?x13822

CONDITIONS OF EMPLOYMENT

Pre-Employment Process: Applicants selected for these positions must pass a background investigation, physical, and verification of employment history and education.

Sponsorship: Please note San Bernardino County is not able to consider candidates who will require visa sponsorship at the time of application or in the future.

Minimum Requirements

Candidates must meet all of the following: LICENSE Must possess and maintain Registered Nurse licensure with the State of California Board of Registered Nursing. CERTIFICATION Must possess and maintain current Healthcare Provider level Basic Life Support (BLS) certification. EXPERIENCE
Must meet one of the following options:

• Option 1: Three (3) years of Medical-Surgical Registered Nurse experience in an acute care hospital.
  -OR-
  
• Option 2: Two (2) years of experience as a Registered Nurse in Case Management or Managed Care.
  

Desired Qualifications

The ideal candidate will have a Bachelor's degree in Nursing with at least five (5) years of experience working in acute care as a Case Manager or similar related experience. One (1) year of CDI experience is preferred.

Selection Process

Application Procedure : Applications will be accepted until a sufficient number of qualified applications are received. To receive priority consideration for this excellent opportunity, please complete and submit the online employment application and supplemental questionnaire as soon as possible. Resumes will not be accepted in lieu of the application and/or supplemental questionnaire.

There will be a competitive evaluation of qualifications based on the information provided in your Application and the Supplemental Questionnaire. The most highly qualified candidates, based on the evaluation results, will be referred for an interview. Be sure to include in your application and supplemental questions your experience in meeting the minimum requirements.

To ensure timely and successful submission of your online application, please allow ample time to complete and submit your application before the posted filing deadline. Applicants will be automatically logged-out if they have not submitted the application and all required materials prior to the posted deadline. Once your application has been successfully submitted you will receive an onscreen confirmation and an email. We recommend that you save and/or print these for your records. Please note, if you do not receive an onscreen confirmation and an email acknowledging our receipt of your application we have not received your application.

If you require technical assistance, please click HERE to review the Government Jobs online application guide , or contact their Toll-Free Applicant Support line at (855) 524-5627. Please note that Human Resources is not responsible for any issues or delays caused by the internet connection, computer or browser used to submit the application.

EEO/ADA: San Bernardino County is an Equal Employment Opportunity (EEO) and Americans with Disabilities Act (ADA) compliant employer, committed to providing equal employment opportunity to all employees and applicants.

ADA Accommodation: If you have a disability and require accommodations in the testing process, submit the Special Testing Accommodations Request Form within one week of a recruitment filing deadline.

Veterans’ Preference: Eligible veterans and their spouse or widow(er) who are not current County employees may be awarded additional Veterans’ Preference points. Click HERE for information and instructions to request Veteran's Preference points.

Please click HERE for important Applicant Information and the County Employment Process

Nurses Unit

The County of San Bernardino offers a range of benefit programs for employees and their eligible dependents. These include health, dental, vision, and life insurance, as well as a variety of voluntary benefits. Programs and benefit amounts vary and are based on bargaining unit, family size, hire date, plan selection, and number of hours worked.

For a summary of benefits,* please click here .

Refer to the appropriate MOU, contact the County's Employee Benefits and Services Division at (909) 387-5787 or visit the Benefits website for more detailed information at hr.sbcounty.gov/employee-benefits/ .

*Retirement benefits subject to change.

Closing Date/Time: 2/21/2025 9:00 AM Pacific

• 

• San Bernardino County

• 9093878304

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