CommonSpirit Health · 3 months ago
Quality Clinical Documentation Improvement RN
United States
Full-time
Remote
Mid Level
$52.15/hr - $77.58/hr
3+ years expCommonSpirit Health is a large health system with care centers throughout California. The Quality Clinical Documentation Improvement RN is responsible for reviewing ambulatory medical records for documentation compliance and providing education to providers while identifying trends and opportunities for improvement.
Health CareMedicalNon Profit
Responsibilities
Reviews high volume of EMR medical records to determine if specific conditions were assessed and documented appropriately; Follows department policies and guidelines on appropriate documentation to billing codes, abstracting information from chart notes based on performance program measures
Identifies claims correction opportunities and submit to appropriate personnel for processing in a timely manner within pre-set acceptable accuracy levels. Tracks trends for each physician to identify potential training areas
Maintains accurate, timely tracking of physician documentation performance using established tools within the department; Alerts management when low performance trends occur
Participates with third-party collaborator to identify trends and to address and resolve gaps in performance standards
Provides chart review guidance and education to team regarding appropriate chart review methodology when necessary; Performs secondary chart reviews when applicable to clarify compliance to coding guidelines
Qualification
Required
3-5 years post licensure experience
Satisfactory completion of a formal Registered Nurse program pursuant to the Division of Allied Health Professions or military training that is equivalent to an accredited Registered Nurse program (determination by Dignity Health Medical Foundation HR department in conjunction with the State Division of Allied Health Professions)
Clear and current CA Registered Nurse (RN) license
Familiarity with an electronic practice management system/EMR
Ability to independently assess, evaluate and interpret clinical information
Ability to identify claim correction opportunities via detailed chart reviews
Demonstrated analytical skills, including the ability to understand clinical compliance guidelines, complex reimbursement structures and the ability to apply contractual and governmental regulations to internal processes
Must possess excellent verbal, written, and interpersonal skills
Strong organizational and time management skills
Mature judgement, self-motivated, and ability to work independently
Schedule, organize, and complete work in accordance with deadlines
Ability to collaborate effectively with all levels of staff
Must possess basic computer skills with Microsoft Word and Excel
Clinical training in an acute care or ambulatory environment
Clinical training in managed care capitated healthcare environment
Preferred
3-5 years broad clinical experience in an ambulatory setting preferred
Bachelors of Nursing (BSN) preferred
Certified Professional Coder (CPC) preferred
Company
CommonSpirit Health
Common Spirit Health is a healthcare organization that provides research programs, home health programs, and virtual care services. It is a sub-organization of CommonSpirit Health.
10001+ employees
Funding
Current Stage
Late StageLeadership Team
Wright Lassiter
Chief Executive Officer
Christine Brocato
System VP, Strategic Innovation
Recent News
2026-02-02
2026-01-20
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