RN Clinical Documentation Integrity Specialist - Remote

Clive Behavioral; Temecula (CA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare services company is seeking a Clinical Documentation Specialist for a fully remote position. The role involves enhancing clinical documentation quality through collaboration with medical professionals. Ideal candidates will have a nursing degree, extensive clinical experience, and relevant certifications. Enjoy competitive compensation and generous benefits while contributing to community health improvements.

Benefits

Generous paid time off

Excellent medical, dental, vision, and prescription drug plans

401(K) with company match

Discounted stock plan

Career development opportunities

Qualifications

• Minimum of five years clinical experience in an acute care setting.
• Current license as a Registered Nurse in California required.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records.
• Collaborate with coders and physicians to improve documentation quality.

Skills

Clinical Documentation Integrity

Organizational Skills

Education

Associate's degree in nursing

Bachelor's degree in nursing

Job description

Employer Industry: Healthcare Services

Why consider this job opportunity:
- Fully remote position providing flexibility in work location
- Competitive compensation and generous paid time off
- Excellent medical, dental, vision, and prescription drug plans
- 401(K) with company match and discounted stock plan
- Career development opportunities within the organization and its subsidiaries
- Supportive and rewarding work environment focused on improving community health

What to Expect (Job Responsibilities):
- Conduct concurrent and retrospective reviews of inpatient medical records to enhance clinical documentation quality
- Collaborate with medical record coders and physicians to improve documentation and reimbursement processes
- Facilitate clarification and specificity in clinical documentation through physician interaction
- Review medical records to identify payer populations and ensure accurate documentation throughout hospitalization
- Analyze patient status and treatment plans to identify gaps in physician documentation

What is Required (Qualifications):
- Associate's degree in nursing from an accredited college or university required
- Minimum of five (5) years of recent clinical experience in an acute care setting required
- Minimum of three (3) years of recent experience performing Clinical Documentation Integrity (CDI) reviews in an inpatient acute care setting required
- Current license as a Registered Nurse in the State of California required
- Current certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required

How to Stand Out (Preferred Qualifications):
- Bachelor's degree in nursing from an accredited college or university preferred
- Minimum of five (5) years of CDI review experience strongly preferred
- Additional certification(s) such as CCDS-O, CCS, or RHIT preferred
- Familiarity with current ICD-10-CM coding guidelines preferred
- Strong organizational skills and ability to handle multiple tasks efficiently

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