RN Clinical Documentation Integrity Specialist - WFH Flexbile

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 7,000 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.

Southwest Healthcare is comprised of five acute care hospitals and several non-hospital access points, including: Corona Regional Medical Center, Palmdale Regional Medical Center, Southwest Healthcare Rancho Springs Hospital, Southwest Healthcare Inland Valley Hospital and Temecula Valley Hospital, Temecula Valley Day Surgery, A+ Urgent Care Centers, Apex Heart Specialists and Riverside Medical Clinics. We've won various awards throughout our region and focus on career development and promotion, where the people are at the core of everything we do. If you are looking for a career and not just a job, you're in the right place! For more information on how to join our dynamic team, please visit our website at www.swhealthcaresystem.com.

Job Summary:

Southwest Healthcare is seeking a Full-Time RN Clinical Documentation Integrity Specialist. 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.

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.
Minimum of three (2) years recent experience performing CDI reviews in an inpatient acute care setting required. Minimum of 3+ years strongly 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) requried.
Additional licensure/certification of 1 or more of the following credentials preferred: CCDS-O, CCS, RHIT.

Other Skills and Abilities:

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.
Responsible for improving the overall quality and completeness of clinical documentation.
Ability to perform under pressure, meet frequent deadlines and tight schedules.

Benefit Highlights:

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!
More information is available on our Benefits Guest Website: UHS Guest Benefits.

Southwest Healthcare is owned and operated by subsidiaries of Universal Health Services, Inc. (UHS), a King of Prussia, PA-based company, one of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

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.

Avoid and Report Recruitment Scams:

We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

Share this job

Related Jobs

Infusion

Full-time

3 weeks ago

Infusion Registered Nurse

Infusion for Health Carlsbad, CA

$50 - $58 / hour

Join Our Team as an Infusion Registered Nurse in Carlsbad, CA! About Us: Infusion for Health is a premier, referral-based infusion center serving patients across California, Arizona, Nevada, Washington, Colorado, and Missouri. Our unique centers feature private, comfortable rooms for a personalized patient experience. We are committed to delivering exceptional infusion therapy in a patient-focused, compassionate environment, supported by a team of skilled professionals. Why Infusion for Health? Patient-Centered Care: Our mission is to provide top-notch service and clinical care in a comfortable setting. Growth Opportunities: As we continue to expand, we offer opportunities for career advancement and professional development. Supportive Environment: Join a team where your expertise is valued, and you can make a real difference in patients’ lives. Position Details: We are seeking a dedicated Infusion Registered Nurse to join our center in Carlsbad, California. Full-Time; Monday to Friday, 40 hours a week. What We Offer: Competitive hourly pay between $50-$58 , with variations based on experience and expertise. Qualifications: Graduate of an accredited School of Professional Nursing. Associate Degree in Nursing required; Bachelor of Science in Nursing preferred. Minimum of 3 years of recent clinical RN experience in ICU, ER, or similar high-acuity settings. Infusion experience preferred, but we are willing to train the right candidate. Valid RN License. Current American Heart Association BLS or ACLS/PALS certification. Skills and Abilities: Proficient in Electronic Medical Records (EMR). Computer literacy, including proficiency in Word, Excel, and Outlook. Strong written and verbal communication skills. Excellent interpersonal skills for team collaboration and patient interaction. Essential Functions: Welcome patients and escort them to their private infusion rooms. Educate patients about their treatments and address any concerns about adverse reactions. Administer prescribed medications and establish IV access, including central lines. Monitor and document patients' conditions and responses to treatments. Ensure accurate and timely EMR documentation. Maintain the flow of patient care and manage emergency situations calmly and effectively. Keep infusion rooms clean and well-stocked. Answer phone calls as needed, adhering to OSHA and HIPAA guidelines. Join Our Growing Team: If you are a compassionate, skilled nurse looking to grow your career in a supportive, patient-focused environment, we want to hear from you! Apply today to become part of the Infusion for Health family and help us continue to deliver exemplary care to our patients. Monday to Thursday

Infusion

Full-time

3 months ago

Infusion Registered Nurse

Infusion for Health Carlsbad, CA

$50 - $58 / hour

Full-time

6 months ago

Clinical Registered Nurse II – Interventional Radiology RN

Tri-City Medical Center Oceanside, CA

Job Locations US-CA-Oceanside Overview Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community. Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs. Position Summary : The Clinical Nurse II (CN II) is responsible for providing direct patient care before, during, and after procedures. This role requires a strong clinical background in critical care. The Clinical Nurse II collaborates with physicians, technologists, and other healthcare professionals to ensure safe and efficient procedural workflows while prioritizing patient safety and comfort. The Clinical Nurse II is responsible for monitoring patients’ vital signs, administering moderate sedation, assisting with vascular and cardiac procedures, and responding to emergent situations as needed. This position requires a deep understanding of hemodynamic monitoring, sterile techniques, and contrast media administration, as well as proficiency in post-procedure recovery and patient education. Compliance with regulatory guidelines, infection control practices, and hospital policies is essential to maintaining high-quality patient care. This role requires strong critical thinking skills, adaptability in high-stress situations, and the ability to provide compassionate, evidence-based care in a fast-paced interventional setting. Major Position Responsibilities : The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization. Patient Care: Coordinate the interprofessional health care team to deliver safe, efficient, patient- centered, timely and equitable care to procedural patients. Conduct comprehensive preoperative assessments to identify patient-specific needs. Monitor and evaluate patient responses intraprocedural, ensuring swift intervention as needed. Act as patient advocate and protect patient dignity and confidentiality. Administer moderate sedation for patients undergoing procedures. Educate patients and families on post-procedure care, including activity restrictions and medication instructions. Manage post-procedural complications, such as bleeding, hypotension, or adverse reactions. Advocate for evidence-based practices in procedural care. Procedural Support: Ensure proper handling of all instruments, equipment, and sterile supplies. Handles and documents specimens according to facility policy and physician orders. Anticipate the needs of the procedural team and maintain a seamless workflow. Able to circulate, scrub, monitor and provide procedural sedation. Assist physicians with interventional radiology and cardiac catheterization procedures, ensuring adherence to sterile technique. Safety and Compliance: Maintain strict adherence to aseptic techniques, infection control protocols and radiation safety. Comply with hospital and regulatory standards, including The Joint Commission, OSHA, and AORN guidelines (during implant procedurals). Adhere to facility policies to ensure safe procedural care, including, but not limited to, patient identification, pre-procedure verification, Universal Protocol, and prevention of unintended retained items. Identify and report safety concerns; demonstrate willingness to address pervasive systemic issues. Monitor supply levels and assist in ordering necessary procedural materials. Safely handle and dispose of biohazardous materials and radiation protection gear. Documentation: Accurately document patient care, interventions and responses in the Electronic Health Record (EHR) according to Patient Standards of Professional Development and Leadership: Provide preceptorship and mentorship to New Graduate Nurses, New Hires, and students, fostering their professional development. Participate in professional development activities, including continuing education, certifications, workshops and quality improvement initiatives. Serve as a resource and advocate for best practices within the procedural department. Function in the charge nurse role as needed. Emergency Preparedness: Recognize and respond to hemodynamic instability, arrhythmias, or respiratory distress. Initiate emergency interventions, including Advanced Cardiac Life Support (ACLS) measures when necessary. Participate in rapid response and code situations. Act decisively in critical situations, such as cardiac arrest and/or stroke, demonstrating advanced clinical skills and composure under pressure. Qualifications: Qualifications RN Experience/Transitional RN Program: Experience Requirement Experienced IR/Cath Lab RN: Two (2) years of experience as a Registered Nurse in Interventional Radiology (IR) or Cardiac Cath Lab, required. Transitional RN Program : Five (5) years of experience as a Registered Nurse in an ED or ICU, or similar critical care department, required. Must be able to scrub and circulate in IR and/or Cath Lab procedure area. Must be able to take call and be onsite within 30 minutes and able to do heavy lifting and pushing. Must be able to wear protective lead apron and thyroid shield. Provide nursing support for non-invasive cardiology and radiology services. Education: Bachelor of Science in Nursing (BSN) or may consider Associate Degree, Nursing (ADN) with five (5) years of experience as a Registered Nurse in Interventional Radiology (IR) or Cardiac Cath Lab (CCL) in lieu of BSN required. Completion of a Critical Care or Interventional Radiology/Cath Lab Training Program, preferred. Licenses: Current California RN License, required Certifications: Current BLS; American Heart Association Healthcare Provider, required. Current ACLS; American Heart Association Healthcare Provider, required. Critical Care Registered Nurse (CCRN) certification, preferred. RCIS (Registered Cardiovascular Invasive Specialist) or CRN (Certified Radiology Nurse), preferred. Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work. *Salary/Hourly wage range for this position is posted. Actual pay will be determined based on verified experience as well as internal equity. TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.

Clinical Registered Nurse II – Med/Surg - Oncology RN

Tri-City Medical Center Oceanside, CA

Job Locations US-CA-Oceanside Overview Tri-City Medical Center has served San Diego County’s coastal communities of Carlsbad, Oceanside and Vista, as well as the surrounding region for more than 60 years and is one of the largest employers in North San Diego County. Tri-City is administered by the Tri-City Healthcare District, a California Hospital District. As a full-service acute care public hospital with over 500 physicians practicing in over 60 specialties, Tri-City is vital to the well-being of our community and serves as a healthcare safety net for many of our citizens. The hospital has received a Gold Seal of Approval® from the Joint Commission showcasing a commitment to safe and effective patient care for the residents of the community. Tri-City Medical Center prides itself on being the home to leading orthopedic, spine and cardiovascular health services while also specializing in world-class robotic surgery, cancer and emergency care. Tri-City’s Emergency Department is there for your loved ones in their time of need and is highly regarded for our heart attack and stroke treatment programs. When minutes matter Tri-City is your source for quality compassionate care close to home. Tri-City partners with over 90 local non-profit and community organizations as part of our COASTAL Commitment initiative. Together we are helping tackle some of our communities’ pressing health and social needs. Position Summary : The Medical-Surgical Registered Nurse (RN) at the Clinical Nurse II (CN II) level is a vital part of the Medical-Surgical team, responsible for delivering high-quality, patient-centered care. This role requires advanced competencies, specialized certifications, and a strong ability to function autonomously while collaborating with interdisciplinary team members to ensure patient safety and optimal patient outcomes. Major Position Responsibilities : The position characteristics reflect the most important duties, responsibilities and competencies considered necessary to perform the essential functions of the job in a fully competent manner. They should not be considered as a detailed description of all the work requirements of the position. The characteristics of the position and standards of performance may be changed by TCMC with or without prior notice based on the needs of the organization. Patient Care: Conduct comprehensive assessments to identify patient needs and develop individualized care plans. Administer medications, perform treatments, and monitor patient responses, intervening as needed. Coordinate with the healthcare team to deliver safe, efficient, and timely care. Act as a patient advocate, ensuring dignity and confidentiality. Demonstrate empathy and compassion for patient experience. Provide education to patients and families about medical conditions, medications, and lifestyle modifications. Advocate for evidence-based practices in Medical-Surgical patient care. Safety and Compliance: Maintain a safe, clean working environment, adhering to infection control and hospital policies. Comply with regulatory standards (e.g., The Joint Commission, OSHA). Identify and report safety concerns proactively. Documentation: Accurately document patient care, interventions and responses in the Electronic Health Record (EHR) according to Patient Standards of care Professional Development and Leadership: Provide preceptorship and mentorship to New Graduate Nurses, New Hires, and students, supporting their professional development. Participate in continuing education and quality improvement initiatives. Serve as a resource for best practices within the Medical-Surgical unit. Act as Relief Charge Nurse as needed. Emergency Preparedness: Respond promptly to patient emergencies (e.g., Rapid Response Team (RRT) situations) with composure and clinical skill. Qualifications: Qualifications RN Experience: Two (2) years of experience as a Registered Nurse in a Medical-Surgical Unit or equivalent setting. Demonstrated ability to manage a diverse patient caseload with common medical and surgical conditions. Ability to work in a fast-paced, high-acuity environment requiring quick decision making and strong teamwork. Oncology Department: Chemotherapy experience required Competencies: Technical Skills: Proficient in basic medical equipment (e.g., IV Pumps, monitors) and medication administration. Critical Thinking: Strong clinical judgment, critical thinking and problem-solving skills to respond to acute changes in patient conditions. Communication: Strong patient care and communication skills with patients, families, and healthcare team members. Education: Bachelor of Science in Nursing (BSN) or may consider Associate Degree, Nursing (ADN) with five (5) years’ experience as a Registered Nurse in a Medical-Surgical or equivalent setting in lieu of BSN, required Licenses: Current California RN License, required Certifications: Current BLS; American Heart Association Healthcare Provider, Current ONS Chemotherapy Immunotherapy Certificate, required (Oncology only) Orthopedic Unit: Orthopedic Nurses Certification (ONC) or equivalent certification, preferred Medical-Surgical Unit: Medical-Surgical Nursing Certification (CMSRN) or equivalent certification, preferred Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work. *Salary/Hourly wage range for this position is posted. Actual pay will be determined based on verified experience as well as internal equity. TCHD is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with a disability.

Full-time

1 month ago

Registered Nurse

DaVita Kidney Care San Marcos, CA

$46 - $63 / hour

Posting Date 04/17/2026 2135 Montiel Rd Bldg B, San Marcos, California, 92069-3511, United States of America We are looking for a self-motivated, organized individual who is passionate about patient care and excited for the opportunity to independently manage their cases with confidence and accountability. As a Home Hemodialysis Nurse (HHD Nurse), you will be providing education on Home Hemodialysis to your patients and their care givers in a clinical setting, which then allows them to dialyze from home. You have responsibility over the complete ongoing care of each patient to ensure their treatment stays on track. Dialysis Experience is NOT required. Nephrology nursing provides a fresh lens&set of skills to those newly entering the field. What you can expect: Provide comprehensive patient care in an independent setting. Apply your "core" nursing skills to assess, diagnose and implement complete care plans as you look at the whole patient. As a case manager, you will track and organize your patients. With the pride of ownership comes the joy of witnessing how your care impacts patients' lives. Empower your patients by teaching them to administer their own dialysis and to take their health back into their own hands. Training patients takes time and mental energy and the rewards of that investment come in seeing the transformation of your patients from feeling sick and afraid, to strong, independent, and able to do the daily things that they love. Educating patients on their options when it comes to dialysis not only helps them own their journey, but also expands the program to people who will benefit greatly from HHD. Wear many hats from Nurse, to Coach, to Leader. You will work independently, while also building deep relationships with patients, support systems, and care partners. Schedule: Typically an 8 hour day Monday through Friday, with weekends and holidays off! Flexibility as you manage your own cases, and as a result own your own schedule. Scheduled home visits and on-call shifts vary by program, and are compensated accordingly. What we'll provide: Clear, and competitive career progression for a lifetime nursing career. If you are new to dialysis, we'll provide a 9-12 week paid training and the support to guide you through to becoming a nephrology nurse. Annual $3,000 tuition reimbursement and potential $25,000 scholarship opportunity. CNN and CDN certification reimbursement. 100+ CEU courses at no cost. Comprehensive benefits package: including medical, dental, vision, 401k match, family resources, mental health resources, back-up child and elder care and so much more. Requirements: Current driver's license, reliable transportation, and vehicle insurance in state of residence Associates Degree in Nursing (A.D.N) from accredited school of nursing required; Bachelor of Science in Nursing (B.S.N); three-year diploma from accredited diploma program may be substituted for nursing degree Basic computer skills and proficiency in MS Word and Outlook You might also have (a.k.a. nice-to-haves): Previous Chronic Hemodialysis, Acute Dialysis, Peritoneal Dialysis (PD), or Home Hemodialysis (HHD) nursing experience Training/Teaching/Healthcare Education background Previous case management experience Familiarity with, or excitement to learn about telehealth technologies Certified Nephrology Nurse (CNN), Certified Dialysis Nurse (CDN) DaVita is a clinical leader! We have the highest percentage of facilities meeting or exceeding CMS's standards in the government's two key performance programs. We expect our teammates to commit to improving patient health through clinical goal setting and quality improvement initiatives. Ready to make a difference in the lives of patients? Take the first step and apply now. Nurses: if this isn't the job for you, perhaps you have a friend who would be a perfect fit. Send them this job link. #LI-SA1 At DaVita, we strive to be a community first and a company second. We want all teammates to experience DaVita as "a place where I belong." Our goal is to embed belonging into everything we do in our Village, so that it becomes part of who we are. We are proud to be an equal opportunity workplace and comply with state and federal affirmative action requirements. Individuals are recruited, hired, assigned and promoted without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, protected veteran status, or any other protected characteristic. This position will be open for a minimum of three days. The Wage Range for the role is $46.00 - $63.00 per hour. For location-specific minimum wage details, see the following link: DaVita.jobs/WageRates Compensation for the role will depend on a number of factors, including a candidate’s qualifications, skills, competencies and experience. DaVita offers a competitive total rewards package, which includes a 401k match, healthcare coverage and a broad range of other benefits. Learn more at https://careers.davita.com/benefits Colorado Residents: Please do not respond to any questions in this initial application that may seek age-identifying information such as age, date of birth, or dates of school attendance or graduation. You may also redact this information from any materials you submit during the application process. You will not be penalized for redacting or removing this information.