RN Clinical Documentation Integrity Specialist - Remote

Southwesthealthcare; Temecula (CA); Remote; USD 70,000 - 110,000; Full time

Job summary

An established industry player is seeking a dedicated RN Clinical Documentation Integrity Specialist to enhance the quality of clinical documentation in a fully remote role. This position involves conducting thorough reviews of inpatient medical records, collaborating with healthcare professionals, and ensuring accurate documentation to support appropriate reimbursement. The ideal candidate will bring extensive clinical experience and a strong understanding of coding guidelines, contributing to improved patient care outcomes. Join a dynamic team committed to health and harmony, and enjoy a rewarding career with ample opportunities for professional development and growth.

Benefits

Competitive Compensation

Generous Paid Time Off

Excellent Medical, Dental, Vision Plans

401(K) with Company Match

Tuition Reimbursement

Career Development Opportunities

Qualifications

• 5+ years of clinical experience in acute care settings required.
• Minimum of 3 years performing CDI reviews in inpatient settings.

Responsibilities

• Review inpatient medical records for documentation quality.
• Collaborate with physicians to improve clinical documentation.

Skills

Clinical Documentation Improvement

Critical Care Knowledge

Medical/Surgical Experience

ICD-10-CM Coding Guidelines

Organizational Skills

Data Collection and Reporting

Education

Associate's Degree in Nursing

Bachelor's Degree in Nursing

Tools

Word Processing Software

Databases

Spreadsheets

Job description

RN Clinical Documentation Integrity Specialist - Remote

Join to apply for the RN Clinical Documentation Integrity Specialist - Remote role at Southwest Healthcare.

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.

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

• 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!

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.

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.