RN Clinical Documentation Integrity Specialist - Remote

Southwesthealthcare; Palmdale (CA); Remote; USD 76,000 - 126,000; Full time

Job summary

Join a leading healthcare provider as an RN Clinical Documentation Integrity Specialist. This full-time, remote position requires expertise in clinical documentation and nursing experience. Successful candidates will improve documentation quality and support reimbursement processes, playing a vital role in patient care outcomes.

Benefits

Competitive Compensation

Generous Paid Time Off

Excellent Medical, Dental, Vision Plans

401(K) with company match

Tuition Reimbursement Program

Qualifications

• 5+ years recent clinical experience in an acute care setting required.
• 3+ years of CDI review experience in an inpatient acute care setting required.
• Current RN license in California and relevant certifications required.

Responsibilities

• Review inpatient medical records for accuracy and completeness.
• Promote documentation quality and improvement with healthcare teams.
• Ensure appropriate reimbursement through detailed documentation.

Skills

Clinical Documentation Integrity

Medical Terminology

Attention to Detail

Organizational Skills

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

Job description

RN Clinical Documentation Integrity Specialist - Remote

2 months ago Be among the first 25 applicants

Get AI-powered advice on this job and more exclusive features.

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! For more information on how to join our dynamic team, please visit our website at www.swhealthcaresystem.com.

Job Summary

Southwest Healthcare is seeking a Full-Time Remote RN Clinical Documentation Integrity Specialist. Duties include but 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.
  
  

Experience/Training/Experience

Qualifications

• 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) requried.
• 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.
• Detailed 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!
  
  

Southwest Healthcare is owned and operated by subsidiaries of Universal Health Services, Inc. (UHS), a King of Prussia, PA-based company, that is one of the largest healthcare management companies in the nation. UHS is not accepting unsolicited assistance from search firms for this employment opportunity. Please, no phone calls or e-mails. All resumes submitted by search firms to any employee at UHS; via e-mail, the Internet or in any other form and/or method without a valid written search agreement in place for the above-listed position will be deemed the sole property of UHS. No fee will be paid in the event the candidate is hired by UHS as a result of the referral or through other means.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.

Notice

At UHS and all subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates with matching skillset and experience with the best possible career at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail etc. If you feel suspicious of a job posting or job-related email, let us know by contacting us at: https://uhs.alertline.com or 1-800-852-3449.

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care and Mental Health Care

Referrals increase your chances of interviewing at Southwest Healthcare by 2x

Palmdale, CA $76,270 - $125,920 1 month ago

Registered Nurse (OB/GYN) (Notional Opportunity)

Registered Nurse - Case Management Director

Palmdale, CA $76,270 - $125,920 1 month ago

Registered Nurse - ICU, Full Time, Night

Palmdale, CA $76,270 - $125,920 5 months ago

Registered Nurse OR - Surgery - Full Time/Days - Req#2013553554

Registered Nurse (RN) IV Therapy - Wellness Spa - Santa Clarita - Full Time

Registered Nurse - Med/Surg2, Full Time, Night

Registered Nurse OR - Surgery - Full Time/Days - Req# 2063867636

Registered Nurse OR - Surgery - Full Time/Days - Req#2047084746

RN Clinical Documentation Integrity Specialist - WFH Flexible

Registered Nurse - Surgery , Full Time, Varied

Palmdale, CA $76,270 - $125,920 1 month ago

Palmdale, CA $76,270 - $125,920 1 month ago

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.