RN Clinical Documentation Integrity Specialist - Remote

Universal Health Services; California, Palmdale (MO, CA); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player in healthcare services is seeking a dedicated Clinical Documentation Improvement Specialist. This role involves conducting thorough reviews of inpatient medical records to ensure accurate documentation and reimbursement processes. The ideal candidate will possess strong clinical experience and a passion for improving healthcare outcomes. With a focus on collaboration with medical professionals, this position offers opportunities for career development and a supportive work environment. Join a team that values excellence and is committed to enhancing patient care through meticulous documentation practices.

Benefits

Competitive compensation

Generous paid time off

Excellent medical, dental, and vision plans

401(K) with company match

Tuition reimbursement program

Career development opportunities

Qualifications

• 5+ years of clinical experience in an acute care setting required.
• Current RN license in California and CCDS or CDIP certification required.

Responsibilities

• Conduct reviews of inpatient medical records to evaluate service utilization.
• Collaborate with healthcare professionals to enhance documentation processes.

Skills

Clinical Documentation Improvement

Critical Thinking

Communication Skills

Organizational Skills

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

Tools

Word Processing Software

Databases

Spreadsheets

Job description

Employer Industry: Healthcare Services

Why consider this job opportunity:

• Competitive compensation and 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 available
• Tuition, CEU, and certification/license reimbursement program
• Opportunities for career development within the organization

What to Expect (Job Responsibilities):

• Conduct clinically based concurrent and retrospective reviews of inpatient medical records to evaluate the utilization and documentation of acute care services
• Collaborate with clinical reviews, medical record coders, and physicians to enhance documentation and reimbursement processes
• Facilitate clarification and specificity in clinical documentation through effective interactions with physicians
• Review medical records to identify payer population as documented upon admission and throughout hospitalization
• Support the accuracy and completeness of clinical information for measuring and reporting physician and hospital outcomes

What is Required (Qualifications):

• Associate's degree from an accredited college or university in nursing required
• Minimum of five (5) years recent clinical experience in an acute care setting required, with critical care or medical/surgical experience preferred
• Minimum of three (3) years recent experience performing CDI reviews in an inpatient acute care setting required
• 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

How to Stand Out (Preferred Qualifications):

• Bachelor's degree from an accredited college or university in nursing preferred
• Additional certification in one or more of the following: CCDS-O, CCS, RHIT preferred
• Familiarity with basic medical laws and ethics, medical terminology, and emergency procedures
• Proficiency in working with word processing, databases, and spreadsheets
• Strong organizational skills and the ability to perform under pressure