RN Clinical Documentation Integrity Specialist - WFH Flexbile

UHS • Corona, CA

88d

About The Position

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Integrity Specialist for our Corona Regional Medical Center location. This position offers a Hybrid/work from home option and provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. 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. May work a hybrid schedule. 3 days onsite required.

Requirements

• 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.
• Minimum of three (2) years recent experience performing CDI reviews in an inpatient acute care setting required.
• 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.

Nice To Haves

• Minimum of 3+ years strongly preferred.
• Additional licensure/certification of 1 or more of the following credentials preferred: CCDS-O, CCS, RHIT.
• Demonstrates knowledge and ensures compliance with The Joint Commission and Title 22 standards and guidelines.
• Demonstrates compliance with Healthcare policies and procedures at all times.
• Working knowledge of current ICD-10-CM coding guidelines, with working knowledge of Medicare reimbursement system required.
• Ability to set priorities and appropriately organize workload and complete assignments in a timely manner.
• Familiarity with basic medical laws and ethics, i.e. consents, confidentiality.
• Knowledge of emergency procedures, medical terminology and medical abbreviations.
• Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public.
• Proficiency in working with word processing, databases and spreadsheets.
• Ability to perform under pressure, meet frequent deadlines and tight schedules.

Responsibilities

• 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.

Benefits

• Challenging and rewarding work environment.
• Competitive Compensation & 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!

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 1,001-5,000 employees