Clinical Document Specialist

University of California San Francisco • San Francisco, CA

6d

About The Position

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 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. This position requires flexibility to orient and work at all UCSF Medical Center locations. 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. In depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes. 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.

Requirements

• 5+ years of related work experience.
• Bachelor’s degree in nursing or related area, and / or equivalent combination of experience / training.
• 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
• CA Nursing license
• Certification as Clinical Documentation Specialist (CCDS)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees