RN Clinical Documentation Integrity Specialist - Hybrid

UHS • $80K — $100K *
Palmdale, CA 93550Hybrid
Healthcare
5 - 7 years of experience
Today
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Job Overview by Ladders

Qualifications

  • Associate's degree in nursing required; Bachelor's preferred.
  • 5+ years clinical experience in acute care settings required.
  • 2+ years experience performing Clinical Documentation Integrity reviews in inpatient settings required; 3+ years preferred.
  • Current California RN license required.
  • Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) certification required.

Responsibilities

  • Improve quality and completeness of clinical documentation.
  • Promote collaboration between clinical reviews, coders, and physicians.
  • Facilitate documentation clarification and advocate for reimbursement.
  • Review medical records to identify payer population documentation.
  • Analyze patient status, treatment plans, and identify documentation gaps.
  • Support the accuracy of clinical information for hospital outcome reporting.
  • Maintain knowledge of ICD-10-CM coding guidelines and Medicare reimbursement.

Benefits

  • 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.
  • Tuition, CEU, certification, and licenses reimbursement program.
  • Career development opportunities within UHS and its 300+ subsidiaries.
Full Job Description
Responsibilities

Job Summary:

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Integrity Specialist for either our Corona Regional Medical Center, Temecula Valley Hospital, Southwest Healthcare Inland Valley hospital or our Palmdale Regional Medical Center location. 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:
  • 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.
  • Responsible for improving the overall quality and completeness of clinical documentation.
  • Working knowledge of current ICD-10-CM coding guidelines, with working knowledge of Medicare reimbursement system required.
  • May work a hybrid schedule. 3 days onsite required.
Qualifications

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 (2) 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) requried.
  • 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.
  • Ability to set priorities and appropriately organize workload and complete assignments in a timely manner.
  • Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public.
  • Must have knowledge of PC and applications.
  • Familiarity with basic medical laws and ethics, i.e. consents, confidentiality.
  • Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public.
  • Ability to work with word processing, databases and spreadsheets.
  • Ability to perform under pressure, meet frequent deadlines and tight schedules.

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

About UHS

UHS Careers

Joining UHS presents an unparalleled opportunity to become part of a leading team of healthcare professionals dedicated to making a difference. UHS, known for its commitment to innovation and leadership in the healthcare sector, offers a variety of job opportunities that cater to a diverse range of skills and experiences.

Explore Job Opportunities

UHS is actively hiring and offers a wide array of positions, from clinical roles to administrative support. Each position at UHS is designed to challenge team members while providing meaningful service to the community. Explore the current job openings and find a career path that suits professional aspirations and skills.

Internship Programs

UHS provides robust internship programs that offer hands-on experience in the healthcare industry. Internships are a cornerstone of professional development, giving participants a chance to deepen practical skills in a real-world setting. These programs are tailored to foster growth and prepare interns for a full-time position within the company.

Professional Growth and Development

UHS believes in nurturing the career growth of its team members through comprehensive professional development programs. These include leadership training, diversity training, and continuous education in the latest healthcare practices, ensuring that every team member has the opportunity to advance their career.

Benefits and Culture

Employment at UHS comes with competitive benefits designed to support the health, well-being, and financial security of each team member and their families. The company culture at UHS is built on a foundation of respect and inclusion, where diversity is celebrated and every voice is heard.

Networking and Innovation

UHS encourages a culture of innovation where team members are motivated to bring forward ideas that drive improvement and efficiency. Networking within the company is supported through various events and internal platforms, helping team members to connect, share insights, and collaborate on projects.

Applying for a Position

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