RN Clinical Documentation Integrity Specialist - Remote

Universal Health Services; Temecula (CA); Remote; USD 70,000 - 110,000; Full time

Job summary

An established industry player in healthcare is seeking a dedicated professional for a fully remote position focused on Clinical Documentation Integrity. This role emphasizes the importance of accurate clinical documentation, ensuring quality and completeness in patient records. The ideal candidate will have a strong nursing background and experience in CDI reviews, advocating for appropriate reimbursement while collaborating with healthcare professionals. Join a supportive and collaborative environment that prioritizes professional growth, offering competitive compensation and generous paid time off. If you are passionate about making a difference in healthcare documentation, this opportunity is perfect for you.

Benefits

Generous Paid Time Off

Medical, Dental, Vision, and Prescription Drug Plans

401(K) with company match

Discounted stock plan

Opportunities for career development

Qualifications

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

Responsibilities

• Conduct reviews of inpatient medical records for quality and completeness.
• Collaborate with clinical reviewers and physicians for documentation enhancement.

Skills

Clinical Documentation Integrity (CDI)

Nursing

ICD-10-CM Coding

Medical Law and Ethics

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

Job description

Employer Industry: Healthcare Services

Why consider this job opportunity:

1. Fully remote position providing flexibility in work environment
2. Competitive Compensation & Generous Paid Time Off
3. Excellent Medical, Dental, Vision, and Prescription Drug Plans
4. 401(K) with company match and discounted stock plan
5. Opportunities for career development within a large healthcare network
6. Supportive and collaborative work environment focused on professional growth

What to Expect (Job Responsibilities):

1. Conduct concurrent and retrospective reviews of inpatient medical records to ensure quality and completeness of clinical documentation
2. Collaborate with clinical reviewers, medical record coders, and physicians to enhance documentation and reimbursement processes
3. Advocate for appropriate reimbursement by facilitating interactions with physicians for clarification of clinical documentation
4. Review medical records to identify payer populations and ensure accurate documentation throughout hospitalization
5. Analyze patient status and treatment plans to identify gaps in physician documentation

What is Required (Qualifications):

1. Associate's degree from an accredited College or University in the field of nursing required
2. Minimum of five (5) years recent clinical experience in an acute care setting required
3. Minimum of three (3) years recent experience performing Clinical Documentation Integrity (CDI) reviews in an inpatient setting required
4. Current license as a Registered Nurse in the State of California required
5. Current certification(s) for Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required

How to Stand Out (Preferred Qualifications):

1. Bachelor's degree from an accredited College or University in the field of nursing preferred
2. Minimum of five (5+) years of CDI review experience strongly preferred
3. Additional licensure/certification in CCDS-O, CCS, or RHIT preferred
4. Strong knowledge of current ICD-10-CM coding guidelines and Medicare reimbursement system
5. Familiarity with basic medical laws and ethics