RN Clinical Documentation Integrity Specialist - Remote

Universal Hospital Services Inc.; California (MO); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a Full-Time Remote RN Clinical Documentation Integrity Specialist to enhance clinical documentation quality. This role involves reviewing medical records, collaborating with healthcare professionals, and ensuring accurate documentation for optimal reimbursement. Join a dynamic team dedicated to providing exceptional healthcare services while enjoying a challenging and rewarding work environment. With opportunities for career development and competitive compensation, this position is perfect for those looking to make a significant impact in the healthcare field.

Benefits

Competitive Compensation

Generous Paid Time Off

Excellent Medical, Dental, Vision Plans

401(K) with Company Match

Tuition Reimbursement Program

Career Development Opportunities

Qualifications

• 5+ years of clinical experience in acute care settings required.
• Current RN license in California and CDI certifications required.

Responsibilities

• Review inpatient medical records for documentation quality and completeness.
• Facilitate collaboration between clinical reviews, coders, and physicians.

Skills

Clinical Documentation Improvement

Critical Care Experience

Medical/Surgical Experience

Emergency Medicine Experience

ICD-10-CM Coding Guidelines

Data Reporting and Analysis

Organizational Skills

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Word Processing Software

Databases

Spreadsheets

Job description

Responsibilities

Join the Southwest Healthcare Team!

About Us:

Creating Health and Harmony, Southwest Healthcare is a comprehensive network of care with convenient hospital and ambulatory care/outpatient locations here to serve the Southern California community. With over 7,000 passionate providers and healthcare employees, our shared goal is to provide convenient access to a wide range of healthcare services in a way that benefits you, your family, and the entire community.

Southwest Healthcare is comprised of five acute care hospitals and several non-hospital access points, including: Corona Regional Medical Center, Palmdale Regional Medical Center, Southwest Healthcare Rancho Springs Hospital, Southwest Healthcare Inland Valley Hospital and Temecula Valley Hospital, Temecula Valley Day Surgery, A+ Urgent Care Centers, Apex Heart Specialists and Riverside Medical Clinics. We've won various awards throughout our region and focus on career development and promotion, where the people are at the core of everything we do. If you are looking for a career and not just a job, you're in the right place!

Job Summary:

Southwest Healthcare is seeking a Full-Time Remote RN Clinical Documentation Integrity Specialist. Duties include but are not limited to:

• Providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. Responsible for improving the overall quality and completeness of clinical documentation.
• Promotes a partnership between the concurrent clinical reviews, medical record coders, and physicians to improve documentation and reimbursement.
• Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement.
• Responsible for reviewing medical records to identify payer population as documented upon admission and throughout the hospitalization.
• Analyzes status of patient, current treatment plan, past medical history and identified possible gaps in physician documentation.
• Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality.
• Fully remote position; provides cross-coverage support throughout Southwest Healthcare Region.

Qualifications

Experience/Training/Experience:

• Associate's degree from an accredited College or University in the field of nursing required.
• Bachelor's degree from an accredited College or University in the field of nursing preferred.
• Minimum of five (5) years recent clinical experience in acute care setting (Critical care, Medical/Surgical or Emergency Medicine) required. Critical Care or Medical/Surgical preferred.
• Minimum of three (3) years recent experience performing CDI reviews in an inpatient acute care setting required. Minimum of 5+ years strongly preferred.

Certifications/Licenses:

• Current license as a Registered Nurse in the State of California required.
• Current certification(s) for Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required.
• Additional licensure/certification of 1 or more of the following credentials preferred: CCDS-O, CCS, RHIT.

Other Skills and Abilities:

• Familiarity with basic medical laws and ethics, i.e. consents, confidentiality.
• Knowledge of emergency procedures, medical terminology and medical abbreviations.
• Proficiency in working with word processing, databases and spreadsheets.
• Strong broad-based clinical knowledge and understanding of anatomy and pathology/physiology of disease processes.
• Ability to work independently in a time-oriented environment is essential.
• Working knowledge of current ICD-10-CM coding guidelines, with working knowledge of Medicare reimbursement system required.
• Working knowledge of inpatient admission criteria.
• Detail-oriented, ability to collect, trend and report data.
• Excellent organizational skills required.
• Ability to perform under pressure, meet frequent deadlines and tight schedules.
• Demonstrates ability to maintain positive relationships and courteous interactions with co-workers, hospital staff, medical staff, etc. regardless of communication method (i.e. telephone, fax, written/verbal, instant message, email, etc.).
• Ability to set priorities that may change and accomplish multiple tasks daily.

Benefit Highlights:

• Challenging and rewarding work environment.
• Competitive Compensation & Generous Paid Time Off.
• Excellent Medical, Dental, Vision and Prescription Drug Plans.
• 401(K) with company match and discounted stock plan.
• SoFi Student Loan Refinancing Program.
• Tuition, CEU, Certification, Licenses Reimbursement program.
• Career development opportunities within UHS and its 300+ Subsidiaries!