RN, Registered Nurse - Emergency Care - Full Time

Responsibilities
Join the Southwest Healthcare Team!

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Integrity - New To Specialty position, onsite at our Corona 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 are 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.

Promoting a partnership between concurrent clinical reviews, medical record coders, and physicians to improve documentation and reimbursement.

Facilitating clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement.

Reviewing medical records to identify payer population as documented upon admission and throughout the hospitalization.

Analyzing status of patient, current treatment plan, past medical history and identifying possible gaps in physician documentation.

Supporting 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

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 years recent clinical experience in an 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.

Detail‑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.

Ability to set priorities that may change and accomplish multiple tasks daily.

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, licenses 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.

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