Perform concurrent and retrospective reviews of inpatient medical records to ensure clinical documentation is accurate and complete. Collaborate with physicians and coders to improve documentation specificity and ensure appropriate reimbursement based on patient severity.
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. 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 - New To Specialty position. Onsite at our Regional office 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.
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.
Requirements
Requires an Associate's degree in nursing, a valid California RN license, and at least five years of recent acute care clinical experience. Proficiency in ICD-10-CM guidelines and Medicare reimbursement systems is required.
associate degree
bachelor degree
Time Management
Organizational Skills
Medical Terminology
Data Reporting
Medical Record Review
Physician Collaboration
Acute Care Nursing
Medicare Reimbursement
Clinical Documentation Improvement
Anatomy And Physiology
ICD-10-CM Coding
Patient Status Analysis
Benefits
Dental Insurance
Vision Insurance
Medical Insurance
Competitive Compensation
Tuition Reimbursement
Generous Paid Time Off
Career Development Opportunities
SoFi Student Loan Refinancing Program
Prescription Drug Plans
Discounted Stock Plan
401(K) With Company Match
CEU Reimbursement
Certification Reimbursement
Licenses Reimbursement
Posting details
Employment type
Full Time
Work arrangement
On Site
Experience
5-10 yrs
Location
Temecula, California
Posted
Jun 1, 2026
Closes
Jun 1, 2027
Application
Employer website
Market context
California CDI RN roles favor acute-care experience
In California, RN Clinical Documentation Integrity roles often draw interest from nurses with recent acute-care backgrounds, especially Critical Care, Med/Surg, or Emergency Medicine. These positions are competitive because employers typically prefer a California RN license, an ADN or higher, and may favor a BSN plus CCDS or CDIP certification. Review the AI-summarized requirements and benefits here to save time, then tailor your application to show documentation accuracy and recent inpatient experience.
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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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.
