RN Clinical Documentation Integrity - Specialty; Onsite

Responsibilities

• Provide clinically based concurrent and retrospective review of inpatient medical records to evaluate utilization and documentation of acute care services, improving overall quality and completeness.
• Promote partnership between concurrent reviews, medical record coders, and physicians to enhance documentation and reimbursement.
• Facilitate clarification and specificity to clinical documentation through interaction with physicians, advocating for appropriate reimbursement.
• Review medical records to identify payer population as documented upon admission and throughout hospitalization.
• Analyze patient status, current treatment plan, past medical history, and identify gaps in physician documentation.
• Support accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes to reflect true severity of illness, intensity of care, and risk of mortality.

Experience/Training:

• Associate's degree in nursing from an accredited college or university.
• Bachelor's degree in nursing preferred.
• Minimum five (5) years recent clinical experience in acute care (Critical Care, Medical/Surgical, or Emergency Medicine) required;
  Critical Care or Medical/Surgical preferred.

Certifications/Licenses:

• Current Registered Nurse license in California required.
• Certification(s) for Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) preferred.

Other

Skills and Abilities:

• Familiarity with basic medical laws and ethics.
• Knowledge of emergency procedures, medical terminology, and abbreviations.
• Proficiency with word processing, databases, and spreadsheets.
• Strong clinical knowledge of anatomy and pathology/physiology of disease processes.
• Ability to work independently in a time‑oriented environment.
• Working knowledge of ICD‑10‑CM coding guidelines and Medicare reimbursement system.
• Understanding of inpatient admission criteria.
• Detail oriented; ability to collect, trend, and report data.
• Excellent organizational skills.
• Ability to perform under pressure, meet deadlines and schedules.
• Maintain positive relationships and courteous interactions with coworkers and clinical staff.
• Set priorities and accomplish multiple tasks daily.

• Challenging and rewarding work environment.
• Competitive compensation and 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, license reimbursement program.
• Career development opportunities within UHS and its 300+ subsidiaries.

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We believe that diversity and inclusion among our teammates is critical to our success.

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