[Hiring] Clinical Documentation Specialist @UCSF

Role 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.

Responsibilities

• Conducts timely concurrent case reviews of clinical documentation in highly complex cases, evaluating quality, consistency, completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM).
• Establishes collaborative working relationships with clinicians, patient care professionals, health information management (HIM), and coding staff.
• Works closely with HIM coding staff to ensure that all clinical documentation is fully compliant and accurately reflects the patient's condition, treatments, and co-morbidities.
• Analyzes highly complex data to identify trends, errors, inconsistencies, variances, or flags that may require an update to the documentation or coding.
• Maintains current knowledge of best practices related to coding, diagnoses, treatment, and reimbursement.

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.
• Advanced critical thinking and problem-solving skills.
• Advanced interpersonal and educational skills.
• Advanced ability to interpret and effectively convey highly complex clinical and technical information.
• In-depth ability to collaborate effectively with senior staff and management across departments.
• Advanced computer proficiency in relevant multiple technology applications.

Requirements

• CA Nursing license (Preferred).
• Certification as Clinical Documentation Specialist (CCDS) (Preferred).
• In-depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation.
• Advanced knowledge of data collection, analysis, reporting techniques and systems.
• Advanced organizational and project management skills.

Benefits

To learn more about the benefits of working at UCSF, including total compensation, please visit: UCSF Benefits .