Clinical Documentation Specialist (1 of 2)
About The Position
The Clinical Documentation Specialist (CDS) evaluates physician documentation using clinical expertise to help ensure that patients’ severity of illness and risk of mortality are accurately represented in the medical record, supporting specificity and coding accuracy. The role works with physicians, clinical staff, health information management (HIM) professionals, and coding staff to ensure discharge diagnoses and coexisting comorbidities fully reflect patients’ clinical status and care. The CDS conducts timely concurrent reviews of complex cases, identifies documentation gaps, clarifies questions, and supports appropriate diagnosis-related group (DRG) assignment. The specialist collaborates with HIM and coding staff on documentation compliance and reviews cases involving mortalities and multiple complications. The role also analyzes complex data to identify trends, errors, inconsistencies, variances, and flags, and recommends strategies to correct documentation or coding issues. The CDS maintains current knowledge of coding, diagnoses, treatment, and reimbursement practices, serves as an expert resource, and contributes to education for clinical and professional staff. Clinical Documentation Integrity (CDI) is part of UCSF Health’s Department of Quality. The team works with faculty service lines to promote best practices in documentation integrity, emphasizing severity of illness, medical complexity, and quality in the medical record. CDI closely monitors Case Mix Index (CMI), risk-adjusted outcomes, and mortality ratings. The CDS reports to a CDI Manager under the leadership of the System Director of CDI.
Requirements
- Bachelor’s degree in nursing or a related area, and/or an equivalent combination of experience and training.
- Flexibility to orient to all patient populations across UCSF Health.
- Five years of current or recent clinical experience in ICU, CCU, ED, or Med Surg, or a combination of education and experience.
- Successful completion of the Nuance pre-hire exam.
- Advanced knowledge and experience with inpatient clinical and operational issues, including diagnoses, treatments, medical procedures, case management, discharge, and effective clinical care systems.
- Advanced critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, assess complex problems, and develop efficient resolutions.
- Advanced interpersonal and educational skills, including collaboration on complex projects and the ability to provide education, training, and resources on coding, reimbursement, and documentation issues.
- Ability to interpret and communicate complex clinical and technical information verbally and in writing, and to prepare presentations, analyses, and reports.
- Ability to collaborate with senior staff and management across departments and provide counsel and guidance on complex functionality, clinical quality, efficiency, and proficiency issues involving multiple technology applications.
- Advanced computer proficiency in relevant technology applications.
Nice To Haves
- California nursing license.
- Clinical Documentation Specialist certification (CCDS).
- In-depth understanding of accurate clinical documentation and medical record review concepts, principles, practices, and regulatory requirements, including SOI, ROM, HIM, ICD-10 coding, DRG systems, compliance standards, Medicare Part A and Part B guidelines, and reimbursement processes.
- Advanced knowledge of data collection, analysis, reporting techniques and systems, and healthcare information related to clinical care, documentation, reporting, and reimbursement.
- Advanced organizational and project management skills, including the ability to lead a team, prioritize tasks, and deliver complex projects on schedule.
Responsibilities
- Conduct timely concurrent reviews of clinical documentation in highly complex cases, evaluating quality, consistency, completeness, and accuracy related to severity of illness and risk of mortality.
- Manage high-volume case assignments, re-reviews, and discharges; research clinical concepts and apply critical thinking, attention to detail, adaptability, and constructive guidance.
- Build collaborative working relationships with clinicians, patient care professionals, HIM and coding staff, and managers in clinical, quality, and information technology areas.
- Identify documentation gaps, clarify questions, and ensure appropriate DRG assignment in complex cases.
- Work with HIM coding staff to ensure documentation is compliant and accurately reflects patients’ conditions, treatments, and comorbidities.
- Review specified cases involving mortalities and multiple complications with the coding team to support final outcomes.
- Analyze complex data to identify trends, errors, inconsistencies, variances, and flags that may require documentation or coding updates.
- Recommend timely strategies for revising codes or correcting clinical documentation to resolve problems and improve compliance.
- Maintain current knowledge of best practices in coding, diagnoses, treatment, and reimbursement.
- Serve as an expert resource to clinical staff and participate in developing education for clinical teams and professional staff.
Benefits
- UCSF provides information about employee benefits and total compensation through its benefits website.
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What This Job Offers
Job Type
Full-time
