Clinical Documentation Specialist (1 of 2)
About The Position
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. The Clinical Documentation Specialist (CDS’) reports to a CDI Manager under the leadership of the System Director of CDI. 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.
Requirements
- Clinical expertise
Responsibilities
- 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.
- Reviews provider documentation and facilitates accurate representation of patients treated at UCSF Health.
- Supports best practices in clinical documentation integrity strategies with an emphasis on severity of illness, medical complexity and quality in the medical record.
- Closely follows Case Mix Index (CMI), risk adjusted outcomes and mortality ratings.
Benefits
- Total compensation information available at https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
