Clinical Documentation Specialist

Clinical Documentation Program

Full Time

86597BR

Job Summary

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

The final salary and offer components are subject to additional approvals based on UC policy.

Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.

The salary range for this position is $121,900 - $277,100 (Annual Rate).

To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html

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.

Required Qualifications

• Bachelor's degree in nursing or related area, and/or equivalent combination of experience/training.
• Five years of current/recent clinical experience working in Intensive Care Unit (ICU), Coronary Care Unit (CCU), Emergency Department (ED), or Medical-Surgical (Med Surg), or a combination of education and experience
• 5+ years of related work experience.
• Successful completion of Nuance pre-hire exam
• This position requires flexibility to orient and work at all UCSF Medical Center locations.
• Advanced knowledge and experience with the clinical and operational issues involved with inpatient care, including the 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 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 Severity of Illness (SOI), Range of Motion (ROM), Hospital Information Management System (HIMS), ICD-10 coding, Diagnosis-Related Group (DRG) systems, 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 management systems 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

At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team.

Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents.

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 our PRIDE values.

In addition to our PRIDE values, 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 at diversity.ucsf.edu

Join us to find a rewarding career contributing to improving healthcare worldwide.

Equal Employment Opportunity

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.

Organization

Health

Job Code and Payroll Title

004902 CLIN DOC SPEC 4 HX

Job Category

Professional and Managerial

Bargaining Unit

University Professional and Technical Employees - Health Care Professionals Unit (UPTE-HX)

Employee Class

Career

Percentage

100%

Location

San Francisco, CA

Campus

TBD

Work Style

Fully Remote

Shift

Days

Shift Length

8 Hours

Additional Shift Details

Monday - Friday