RN Clinical Documentation Integrity - New to Specialty (Onsite)

Full-Time Rn Clinical Documentation Integrity - New To Specialty

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Integrity - New To Specialty position. Onsite at our Palmdale Regional Medical Center location. We encourage Registered Nurses who are new to the CDI specialty to apply. Comprehensive training will be provided. Duties include but not limited to: Providing clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. 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.

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. 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) preferred. Other Skills and Abilities: Familiarity with basic medical laws and ethics, i.e. consents, confidentiality. Knowledge of emergency procedures, medical terminology and medical abbreviations. Proficiency in working with word processing, databases and spreadsheets. Strong broad based clinical knowledge and understanding of anatomy and pathology/physiology of disease processes. Ability to work independently in a time oriented environment is essential. Working knowledge of current ICD-10-CM coding guidelines, with working knowledge of Medicare reimbursement system required. Working knowledge of inpatient admission criteria. Detailed oriented, ability to collect, trend and report data. Excellent organizational skills required. Ability to perform under pressure, meet frequent deadlines and tight schedules. Demonstrates ability to maintain positive relationships and courteous interactions with co-workers, hospital staff, medical staff, etc. regardless of communication method (i.e. telephone, fax, written/verbal, instant message, email, etc.). Ability to set priorities that may change and accomplish multiple tasks daily.