DESCRIPTION

The Clinical Documentation Specialist role 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.

Key Responsibilities:

• Performs complex reviews of patient’s medical documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).
• Establishes productive working relationships in regular communications with clinicians, patient care staff, and health information management (HIM), and coding personnel, working on complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment.
• Collaborates with HIM coding staff to ensure that all clinical documentation at discharge is compliant and accurately reflects the patient's condition, treatments, and any co-morbidities.
• Participates in medical record reviews on specific cases involving mortalities, complications, and other situations requiring secondary reviews.
• Analyzes complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement.
• Recommends timely and effective strategies for revising or correcting clinical documentation to resolve problems and improve compliance.
• Monitors changes and updates in regulatory requirements for clinical documentation.
• Reviews and analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.
• Maintains current knowledge of ICD-10 coding guidelines, DRG systems, and reimbursement issues.
• Serves as an educational resource to all levels of clinical staff and contributes to the development of curriculum for in service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement.
• Other duties as assigned.

While not required, a cover letter is highly recommended when applying to this position.

MINIMUM QUALIFICATIONS

• Seven (7 ) or more years of relevant inpatient clinical experience OR three (3 ) or more years of relevant inpatient clinical experience and a bachelor's degree in nursing or related area.

• Experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, complications, co-morbidities, discharge, and other practices that are part of effective clinical care systems.

• Professional work experience as Clinical Documentation Specialist. If insufficient application pool, department may consider clinicians (RNs or MDs) with three (3 ) or more years of experience in acute adult Telemetry and/or ICU.

• Demonstrated adult ICU or Telemetry work experience.

• Effective interpersonal skills and ability to work with all levels of physicians, advanced practice providers and staff.

PREFERRED QUALIFICATIONS

• MSN or other Master’s degree.

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP).

SPECIAL CONDITIONS

• The hiring salary range of the Clinical Documentation Specialist 3 is $105,000-135,000. The hiring salary range of the Clinical Documentation Specialist 4 is $120,000-195,000 commensurate with CDS experience. The level 4 requires an active CCDS/CDIP certification.
• Must be able to work various hours and locations based on business needs.
• Must be able to work onsite throughout UC San Diego Health’s facilities full time Mon-Fri, duties as assigned.
• This position is located primarily in La Jolla, but may need to work in Hillcrest and East Campus based on business needs.
• Employment is subject to a criminal background check and pre-employment physical.

If employed by the University of California, you will be required to comply with our Policy on Vaccination Programs, which may be amended or revised from time to time. Federal, state, or local public health directives may impose additional requirements.
If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community.

UC San Diego is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

For the University of California’s Affirmative Action Policy please visit: https://policy.ucop.edu/doc/4010393/PPSM-20 For the University of California’s Anti-Discrimination Policy, please visit: https://policy.ucop.edu/doc/1001004/Anti-Discrimination

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening.