What are the responsibilities and job description for the Clinical Documentation Specialist position at UCSF Health?
Job Description
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 coexisting co-morbidities are a complete reflection of the patient’s clinical status and care. Involves education and training to physicians and clinical staff (nurses and therapists) as part of the onboarding and as rules and regulations change in the IRF level of care. The final salary and offer components are subject to additional approvals based on UC policy.
Qualifications
Required Qualifications :
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 coexisting co-morbidities are a complete reflection of the patient’s clinical status and care. Involves education and training to physicians and clinical staff (nurses and therapists) as part of the onboarding and as rules and regulations change in the IRF level of care. The final salary and offer components are subject to additional approvals based on UC policy.
Qualifications
Required Qualifications :
- Min 2 years Clinical experience post-grad in a hospital setting.
- Working 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.
- Detail oriented, with demonstrated ability to effectively manage time, see tasks through to completion, organize competing priorities, and effectively address complex, urgent issues as they arise.
- Demonstrated critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess problems to develop multiple potential solutions.
- Demonstrated interpersonal and educational skills, with the ability to collaborate effectively with clinical-care professionals, and to serve as an educational resource on coding, reimbursement, and other clinical documentation issues.
- Demonstrated ability to interpret and effectively explain clinical and technical information both verbally and in writing, and to contribute to presentations, reports, and analyses as assigned.
- Demonstrated ability to work with senior staff and managers and to provide recommendations on issues of functionality, clinical quality, and efficiency.
- Demonstrated computer proficiency in relevant multiple technology applications.
- Has flexibility to work across the system
- Bachelor's degree in PT, OT or Master in SLP or related area, and / or equivalent combination of experience / training California License on respective fields (PT, OT, SLP or RN)
- Working knowledge 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.
- Working knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement.
- PT