Clinical Documentation Specialist*
Apply NowCompany: County of San Bernardino, CA
Location: Colton, CA 92324
Description:
Salary : $99,736.00 - $130,873.60 Annually
Location : Colton, CA
Job Type: Full-time
Job Number: 25-21014-01
Department: Arrowhead Regional Medical Center
Division: 91011- Case Management
Opening Date: 02/08/2025
Closing Date: 2/21/2025 9:00 AM Pacific
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
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:
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:LICENSEMust possess and maintain Registered Nurse licensure with the State of California Board of Registered Nursing.CERTIFICATIONMust possess and maintain current Healthcare Provider level Basic Life Support (BLS) certification.EXPERIENCE
Must meet one of the following options:
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
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
*Retirement benefits subject to change.
01
Instructions: The information on the application and your responses to the following supplemental questions will be used in a competitive evaluation of qualifications. Experience listed on this questionnaire must also be listed and fully detailed in the work experience section of your application.
02
License: Do you possess a California Registered Nurse license?
03
License: Indicate your current California Registered Nurse license number and expiration date in the following format: California RN 123456, expires 1/31/2025. If you do not possess a California registered nurse license, indicate "N/A." Incomplete information will result in disqualification.
04
Education: Do you possess a Bachelor's degree in Nursing?
05
Med/Surg Experience: List the Employer(s), your position title, and dates of employment in which you gained your Med/Surg experience.
Example: ABC Acute Care Center, Med/Surg/Tele Nurse, 05/01/2015- Present.If you do no possess this experience, enter N/A.
06
Case Management Experience: List the Employer(s), your position title, and the dates of employment in which you gained your Case Management experience.
Example: ABC Regional Hospital, Case Management Nurse, 08/10/2010- 05/22/2022.If you do not possess this experience, enter N/A.
07
Electronic Health Record Experience: List the Employer(s), your position title, and the dates of employment in which you gained experience working with Electronic Health Records (EHR) and/or Epic. Describe your duties for each, as applicable.
Example: ABC Regional Hospital, Case Management Nurse, 08/10/2010 - 05/22/2022. Duties completed: Patient documentation, Patient Flow and Bed Monitoring, Reporting Vitals, Coordinating with other healthcare staff.
08
Applicant Acknowledgement - Notification via email: As part of our efforts to increase efficiency and promote conservation of resources, human resources uses email to communicate with applicants. Therefore, all future communications regarding this recruitment, including applicant status and testing notifications, will be made via email. Each applicant needs their own email address. We strongly encourage you, as an applicant, to ensure that the email address you have provided us with your application is current, secure, confidential, and readily accessible to you. Adjust Spam and/or other filters so that our emails are accepted. Please carefully read any notices that we send you and follow any instructions provided in a timely manner. We will not be responsible in any way if you do not receive our emails (i.e., for the non-delivery of our emails or if you fail to check your e-mail on a timely basis).
09
**ATTENTION GMAIL USERS**
We have become aware of an increase in Gmail's spam filter sensitivity. Due to this change, it is possible that emails coming from San Bernardino County Human Resources may be marked as spam and will not make it into your Gmail inbox.
For your convenience, the attached PDF document contains a step-by-step guide to create and apply filters within Gmail. Click this link to Once downloaded, follow the instructions so that you will receive future emails from San Bernardino County Human Resources.
Note: If you apply the filters and still do not receive emails from San Bernardino County Human Resources you can check your (Neogov) account inbox. All notifications will appear there.
10
Applicant Acknowledgement - Application Complete: Thank you for taking the time to complete this application and supplemental questionnaire. Please be sure to review all information provided prior to submitting it as you cannot update or revise it once submitted. Your submitted application will be reviewed and evaluated as is. Please do not refer to a resume or other documentation in lieu of completing the employment history section or responding to the supplemental questions; they will not be reviewed or considered.
Once your application has been successfully submitted, you will receive an onscreen confirmation and an email confirmation will be sent to the email address listed on your application. 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.
Required Question
Location : Colton, CA
Job Type: Full-time
Job Number: 25-21014-01
Department: Arrowhead Regional Medical Center
Division: 91011- Case Management
Opening Date: 02/08/2025
Closing Date: 2/21/2025 9:00 AM Pacific
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:
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:LICENSEMust possess and maintain Registered Nurse licensure with the State of California Board of Registered Nursing.CERTIFICATIONMust 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
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
*Retirement benefits subject to change.
01
Instructions: The information on the application and your responses to the following supplemental questions will be used in a competitive evaluation of qualifications. Experience listed on this questionnaire must also be listed and fully detailed in the work experience section of your application.
- I have read and understand the above statement.
02
License: Do you possess a California Registered Nurse license?
- Yes
- No
03
License: Indicate your current California Registered Nurse license number and expiration date in the following format: California RN 123456, expires 1/31/2025. If you do not possess a California registered nurse license, indicate "N/A." Incomplete information will result in disqualification.
04
Education: Do you possess a Bachelor's degree in Nursing?
- Yes
- No
05
Med/Surg Experience: List the Employer(s), your position title, and dates of employment in which you gained your Med/Surg experience.
Example: ABC Acute Care Center, Med/Surg/Tele Nurse, 05/01/2015- Present.If you do no possess this experience, enter N/A.
06
Case Management Experience: List the Employer(s), your position title, and the dates of employment in which you gained your Case Management experience.
Example: ABC Regional Hospital, Case Management Nurse, 08/10/2010- 05/22/2022.If you do not possess this experience, enter N/A.
07
Electronic Health Record Experience: List the Employer(s), your position title, and the dates of employment in which you gained experience working with Electronic Health Records (EHR) and/or Epic. Describe your duties for each, as applicable.
Example: ABC Regional Hospital, Case Management Nurse, 08/10/2010 - 05/22/2022. Duties completed: Patient documentation, Patient Flow and Bed Monitoring, Reporting Vitals, Coordinating with other healthcare staff.
08
Applicant Acknowledgement - Notification via email: As part of our efforts to increase efficiency and promote conservation of resources, human resources uses email to communicate with applicants. Therefore, all future communications regarding this recruitment, including applicant status and testing notifications, will be made via email. Each applicant needs their own email address. We strongly encourage you, as an applicant, to ensure that the email address you have provided us with your application is current, secure, confidential, and readily accessible to you. Adjust Spam and/or other filters so that our emails are accepted. Please carefully read any notices that we send you and follow any instructions provided in a timely manner. We will not be responsible in any way if you do not receive our emails (i.e., for the non-delivery of our emails or if you fail to check your e-mail on a timely basis).
- I acknowledge that I have read, understood, and agree to the above.
09
**ATTENTION GMAIL USERS**
We have become aware of an increase in Gmail's spam filter sensitivity. Due to this change, it is possible that emails coming from San Bernardino County Human Resources may be marked as spam and will not make it into your Gmail inbox.
For your convenience, the attached PDF document contains a step-by-step guide to create and apply filters within Gmail. Click this link to Once downloaded, follow the instructions so that you will receive future emails from San Bernardino County Human Resources.
Note: If you apply the filters and still do not receive emails from San Bernardino County Human Resources you can check your (Neogov) account inbox. All notifications will appear there.
- I understand
10
Applicant Acknowledgement - Application Complete: Thank you for taking the time to complete this application and supplemental questionnaire. Please be sure to review all information provided prior to submitting it as you cannot update or revise it once submitted. Your submitted application will be reviewed and evaluated as is. Please do not refer to a resume or other documentation in lieu of completing the employment history section or responding to the supplemental questions; they will not be reviewed or considered.
Once your application has been successfully submitted, you will receive an onscreen confirmation and an email confirmation will be sent to the email address listed on your application. 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.
- I acknowledge that I have reviewed my application and understand that I will not be able to update or revise any part of it once submitted.
Required Question