RN Clinical Documentation Integrity Specialist - Hybrid

Responsibilities Join the Southwest Healthcare Team! Southwest Healthcare is a comprehensive network of care with convenient hospital and ambulatory care/outpatient locations serving the Southern California community. Our shared goal is to provide convenient access to a wide range of healthcare services that benefit patients, their families, and the community. Job Summary Southwest Healthcare is seeking a full‑time RN Clinical Documentation Integrity Specialist for locations including Corona Regional Medical Center, Temecula Valley Hospital, Inland Valley Hospital, and Palmdale Regional Medical Center. The position offers a hybrid/work‑from‑home option and involves concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute‑care services. Improve the overall quality and completeness of clinical documentation. Promote a partnership between concurrent clinical reviews, medical‑record coders, and physicians to enhance documentation and reimbursement. Facilitate clarification and specificity to 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 patient status, current treatment plan, past medical history, and identify gaps in physician documentation. Support the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. Maintain a 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 in nursing from an accredited institution required. Bachelor's degree in nursing preferred. Minimum of five (5) years of recent clinical experience in an acute‑care setting (critical care, medical/surgical, or emergency medicine) required. Critical care or medical/surgical preferred. Minimum of three (3) years of recent experience performing CDI reviews in an inpatient acute‑care setting required; 3+ years strongly preferred. Certifications & Licenses Registered Nurse license in California required. Current certification(s) as Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Improvement Practitioner (CDIP) required. Additional licensure/certification of CCDS‑O, CCS, or RHIT preferred. Other Skills & Abilities Knowledge of The Joint Commission and Title 22 standards and guidelines. Compliance with healthcare policies and procedures at all times. Ability to set priorities and organize workload to complete assignments timely. Strong interpersonal skills with clinical personnel and the public. Proficiency with PC applications. Familiarity with basic medical laws and ethics, including consents and confidentiality. Ability to work with word processing, databases, and spreadsheets. Ability to perform under pressure, meet frequent deadlines, and manage 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 Universal Health Services