Clinical Documentation Specialist (1 of 2)

Job Description

Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient's severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

Reporting relationship:

The Clinical Documentation Specialist (CDS') reports to a CDI Manager under the leadership of the System Director of CDI.

Department Description

Clinical Documentation Integrity (CDI) is a team within the Department of Quality that reviews provider documentation and facilitates accurate representation of patients treated at UCSF Health. Through collaborative relationships with Faculty service lines, CDI supports best practices in clinical documentation integrity strategies with an emphasis on severity of illness, medical complexity and quality in the medical record. CDI closely follows Case Mix Index (CMI), risk adjusted outcomes and mortality ratings.

Qualifications

REQUIRED QUALIFICATIONS - Bachelor's degree in nursing or related area, and/or equivalent combination of experience/training. - This position requires flexibility to orient to all patient populations across UCSF Health. - Five years of current/recent clinical experience working in ICU, CCU, ED, or Med Surg, or a combination of education and experience - Successful completion of Nuance pre-hire exam - Advanced knowledge and experience with the clinical and operational issues involved with inpatient care, including diagnoses, treatments, medical procedures, case management, discharge, and other practices that are part of effective clinical care systems. - Advanced critical thinking and problem-solving skills to manage multiple levels of information and responsibilities and quickly assess highly complex problems to develop an expedient path of resolution. - Advanced interpersonal and educational skills, with the ability to collaborate effectively on highly complex projects with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues. - Advanced ability to interpret and effectively convey highly complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports. - In depth ability to collaborate effectively with senior staff and management across departments and to provide counsel and guidance on highly complex issues of functionality, clinical quality, efficiency, and proficiency in relevant multiple technology applications. - Advanced computer proficiency in relevant multiple technology applications. PREFERRED QUALIFICATIONS - CA Nursing license - Certification as Clinical Documentation Specialist (CCDS) - In-depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIM, ICD-10 coding, DRG system, standards of compliance, relevant Medicare Part A and Part B guidelines, and other reimbursement processes. - Advanced knowledge of data collection, analysis, reporting techniques and systems, and of health care information related to clinical care, documentation, reporting, and reimbursement. - Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see highly complex projects through from inception to completion on schedule.

About UCSF

The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world's leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells.

Pride Values

UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as https://www.ucsf.edu/about/mission-and-values . In addition to , UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available https://diversity.ucsf.edu/ . Join us to find a rewarding career contributing to improving healthcare worldwide.

EEO Statement

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.