RN Clinical Documentation Integrity Specialist - WFH Flexbile

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

Job Summary:

Southwest Healthcare is seeking a Full‑Time RN Clinical Documentation Integrity Specialist. This position offers a Hybrid/work from home option and provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services.

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.

Experience/Training/

Experience:

• 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 3+ 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:

• Demonstrates knowledge and ensures compliance with The Joint Commission and Title 22 standards and guidelines.
• Demonstrates compliance with Healthcare policies and procedures at all times.
• Working knowledge of current ICD‑10‑CM coding guidelines, with working knowledge of Medicare reimbursement system required.
• Ability to set priorities and appropriately organize workload and complete assignments in a timely manner.
• Familiarity with basic medical laws and ethics, i.e. consents, confidentiality.
• Knowledge of emergency procedures, medical terminology and medical abbreviations.
• Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public.
• Proficiency in working with word processing, databases and spreadsheets.
• Responsible for improving the overall quality and completeness of clinical documentation.
• Ability to perform under pressure, meet frequent deadlines and tight schedules.

• 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!
• More information is available on our Benefits Guest Website: UHS Guest Benefits.

Southwest Healthcare is owned and operated by…