RN Clinical Documentation Integrity Specialist - Hybrid

Job Summary Southwest Healthcare is seeking a Full‑Time RN Clinical Documentation Integrity Specialist for Corona Regional Medical Center, Temecula Valley Hospital, Inland Valley Hospital, or Palmdale Regional Medical Center. This hybrid/work‑from‑home position involves clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. Responsibilities Improve the overall quality and completeness of clinical documentation. Promote a partnership between concurrent clinical reviews, medical record coders, and physicians to improve documentation and reimbursement. Facilitate clarification and specificity in clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement. Review medical records to identify payer population as documented upon admission and throughout the hospitalization. Analyze status of patient, current treatment plan, past medical history, and identified gaps in physician documentation. Ensure 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. Maintain working knowledge of current ICD‑10‑CM coding guidelines and Medicare reimbursement system. Work a hybrid schedule; 3 days onsite required. Qualifications Experience / Training Associate’s degree from an accredited college or university in nursing required. Bachelor’s degree in nursing preferred. Minimum of five 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 years recent experience performing CDI reviews in an inpatient acute care setting required; three or more years strongly preferred. Certifications / Licenses Current license as a Registered Nurse in the State of California required. Current certification as a Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required. Additional licensure or certification of one or more of the following credentials preferred: CCDS‑O, CCS, RHIT. Other Skills and Abilities Demonstrate knowledge of, and compliance with, The Joint Commission and Title 22 standards and guidelines. Demonstrate compliance with healthcare policies and procedures at all times. Set priorities and organize workload, completing assignments in a timely manner. Relate to clinical personnel and medical staff, interacting well with the public. Have knowledge of PC and applications. Familiarity with basic medical laws and ethics, such as consent and confidentiality. Perform under pressure, meeting frequent deadlines and tight schedules. Use word processing, databases, and spreadsheets effectively. 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, 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. #J-18808-Ljbffr Universal Health Services, Inc.