RN Clinical Documentation Integrity Specialist - Hybrid

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. Responsibilities Join the Southwest Healthcare Team! We are 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 Palmdale Regional Medical Center. This position offers a hybrid/work‑from‑home option and requires a support of clinical documentation reviews of inpatient medical records to evaluate utilization and documentation of acute care services. Responsible for improving the overall quality and completeness of clinical documentation. Promotes a partnership between 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. Reviews medical records to identify payer population as documented upon admission and throughout the hospitalization. Analyzes status of the patient, current treatment plan, past medical history, and identifies 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. Has working knowledge of current ICD‑10‑CM coding guidelines and Medicare reimbursement system. May work a hybrid schedule; 3 days onsite required. Qualifications Associate’s degree in nursing from an accredited college or university required. Bachelor’s degree in nursing preferred. Minimum of five (5) years recent clinical experience in an acute care setting (critical care, medical/surgical, or emergency medicine) required; critical care or medical/surgical preferred. Minimum of two (2) years recent experience performing CDI reviews in an inpatient acute care setting required; three (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 or certification of 1 or more of the following credentials preferred: CCDS‑O, CCS, RHIT. Other Skills and Abilities Knowledge of 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 organize workload to complete assignments in a timely manner. Ability to relate to clinical personnel and medical staff and interact well with the public. Knowledge of PC and applications. Familiarity with basic medical laws and ethics, such as consents and confidentiality. 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 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 and license reimbursement program. Career development opportunities within UHS and its 300+ subsidiaries. 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 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. #J-18808-Ljbffr Southwest Healthcare