CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days

University of California, Irvine • Irvine, CA

10h

About The Position

Position Summary: The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.

Requirements

• Strong clinical knowledge with ability to interpret clinical documentation
• Must possess the skill, knowledge and ability essential to the successful performance of assigned duties
• Must demonstrate customer service skills appropriate to the job
• Must be available for occasional weekend coverage
• Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics
• Five (5) or more years of clinical experience as either an RN or Physician and 3 years’ experience in CDI
• Familiarity with Utilization Review criteria
• Familiarity of Joint Commission and CMS requirements
• Excellent written and verbal communication skills in English
• Critical thinking skills to problem solve and communicate with physicians on clinical issues
• CDI Credential (CCDS or CDIP)
• Bachelor of Science in Nursing or Medical School Graduate
• Ability to maintain a work pace appropriate to the workload
• Ability to influence and work collaboratively with physicians and all levels of staff
• Ability to establish and maintain effective working relationships across the Health System
• Must be able to provide proof of work authorization

Nice To Haves

• Previous experience with comprehensive chart / record review
• Master’s degree with an emphasis in health care related fields (nursing, epidemiology, etc.)
• Knowledge of University and medical center organizations, policies, procedures and forms
• Experience working within EPIC and 3M 360 Encompass CAC
• CCS credential

Responsibilities

• facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record
• Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement
• Educates others on documentation guidelines on an ongoing basis
• Collects and analyzes data to provide reports and make recommendations

Benefits

• medical insurance
• sick and vacation time
• retirement savings plans
• access to a number of discounts and perks

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 101-250 employees