RN Clinical Documentation Integrity Specialist (CDIS) - Onsite

Job Description

Responsibilities

Join the Southwest Healthcare Team!

About Us:

Creating Health and Harmony, Southwest Healthcare is a comprehensive network of care with convenient hospital and ambulatory care/outpatient locations here to serve the Southern California community. With over 7, passionate providers and healthcare employees, our shared goal is to provide convenient access to a wide range of healthcare services in a way that benefits you, your family, and the entire community.

Job Summary:

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Integrity Specialist. This position will be onsite at Palmdale Regional Medical Center and 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--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.

Benefit Highlights:

• Challenging and rewarding work environment.
• Competitive Compensation & Generous Paid Time Off.
• Excellent Medical, Dental, Vision and Prescription Drug Plans.
• (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 + Subsidiaries!

Southwest Healthcare is owned and operated by subsidiaries of , a King of Prussia, PA-based company, that is one of the largest healthcare management companies in the nation. UHS is not accepting unsolicited assistance from search firms for this employment opportunity. Please, no phone calls or e-mails. All resumes submitted by search firms to any employee at UHS; via e-mail, the Internet or in any other form and/or method without a valid written search agreement in place for the above-listed position will be deemed the sole property of UHS. No fee will be paid in the event the candidate is hired by UHS as a result of the referral or through other means.