HCA, Hospital Corporation of America Registered Nurse Clinical Documentation Spec (CDI) FT days in Las Vegas, Nevada

Voted the Best Hospital in Las Vegas,

Utilizing advanced digital technology and an accomplished medical staff, Southern Hills Hospital's advanced care and superior service make for better outcomes and an exceptional patient experience.

The Joint Commission, the leading accreditor of healthcare organizations in America, recognized Southern Hills Hospital as a /Top Performer on Key Quality Measures®/ for 2010, 2011, 2012 and 2013 - the only Southern Nevada hospital to earn this recognition for four consecutive years.

  • Southern Hills Hospital is the first institution in the state of Nevada to be recognized by the American Heart Association as a leading hospital in cardiology through their compliance with the “Get with the Guidelines - Heart Failure” program.

  • In addition, Southern Hills Hospital earned The Joint Commission's Gold Seal of Approval® for its Alzheimer's disease program by demonstrating compliance with The Joint Commission's national standards for health care quality and safety in disease-specific care.

  • We have also partnered with award-winning spine physicians from the Nevada Neurosciences Institute.

    The hospital is a member of the respected Sunrise Health System consisting of Sunrise Hospital, Sunrise Children's Hospital, MountainView Hospital and several surgery and diagnostic imaging centers offering a complete range of specialized and technologically advanced services.


    The Clinical Documentation Specialist is a registered nurse who demonstrates a leadership role in continuous quality management through promotion of optimal documentation of patient clinical status in the medical record. Duties include concurrent and retrospective review of medical records, communication of documentation requirements, and monitoring of compliance with fundamental and essential documentation.

  • The Clinical Documentation Specialist records and analyzes data, identifies trends, and reports barriers to ideal endorsement of DRG’s.

  • The Clinical Documentation Specialist uses expertise to support the highest standard of ethical and compliant management of medical records through education, support and collaboration with healthcare workers across the continuum of the acute healthcare experience.

    The successful candidate will be able to perform department specific expectations, which include but are not limited to the following:

  • Provides for effective communication and information transfer

  • Interacts productively with: Facility Case Management Director; Patient Access Management; Patient Accounting; Finance; Payers; Patients; Families; Physicians; Physician Representatives; CFO; HIM; and other members of the healthcare team

  • Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality

  • Uses the DRG Worksheet proficiently to identify and communicate co-morbidities/complications

  • Demonstrates respect in interactions with the HIM coding team

  • Uses the chain of command to escalate problems or situations requiring administrative intervention

  • Identifies potential financial risk factors and notifies the appropriate individuals

  • Identifies and tracks and reports compliance with query responses

  • Identifies and notifies Case Management Director, HIM Director and CFO regarding unfavorable trends in DRG coding both concurrent and retrospective to patient hospital visits

  • Refers / Collaborates with Social Service and Case Management personnel on high risk cases

  • Facilitates optimal clinical documentation to support severity of illness and risk of mortality through collaboration, education and supportive communication with physicians, physician representatives and registered nurses

  • Demonstrates knowledge and proficiency in thorough clinical review using written and electronic documentation systems

  • Demonstrates knowledge and basic proficiency in DRG coding and reporting systems

  • Utilizes strong analytical skills, including data compilation and attention to detail

  • Maintains compliance with departmental and house wide hospital policies and procedures

  • Maintains current knowledge of Medicare/Commercial procedures and requirements as they apply to DRG assignment and billing practices



  • Graduate of an accredited school of nursing

  • BSN strongly preferred


  • Current license to practice as a Registered Nurse in the State of Nevada


  • Minimum of 5 years of clinical healthcare experience in an acute care hospital, required

  • Minimum of 2 years of acute care case management experience

  • Knowledge of PC based computer software (i.e. Word, Excel, Access, or similar system) preferred.


  • CPR

Title: Registered Nurse Clinical Documentation Spec (CDI) FT days

Location: Nevada-Las Vegas-Southern Hills Hospital and Medical Center

Requisition ID: 08967-3619