Clinical Documentation Specialist (1 of 2)

About the role

The Clinical Documentation Specialist (CDS) evaluates physician documentation to ensure accurate portrayal of patient severity of illness and risk of mortality in medical records. They interact with physicians, clinical staff, and health information management professionals to facilitate accurate clinical documentation.

Responsibilities

• Evaluates clinical documentation in complex cases, ensuring quality, consistency, completeness, and accuracy for SOI and ROM.
• Manages high-volume case assignments, re-reviews, and discharges.
• Establishes collaborative relationships with clinicians, HIM, and coding staff.
• Works on complex cases to identify documentation gaps, clarify questions, and ensure DRG appropriateness.
• Collaborates with HIM coding staff to ensure clinical documentation is fully compliant and accurately reflects patient condition.
• Analyzes complex data to identify trends, errors, inconsistencies, variances, or flags requiring updates to documentation or coding.
• Serves as an expert resource to clinical staff and participates in education on coding, reimbursement, and documentation issues.
• Maintains current knowledge of coding, diagnoses, treatment, and reimbursement best practices.

Qualifications

• Five years of recent clinical experience in ICU, CCU, ED, or Med Surg, or equivalent combination of education and experience.
• Bachelor’s degree in nursing or related field, and/or successful completion of Nuance pre-hire exam.
• Advanced knowledge and experience with inpatient care, diagnoses, treatments, medical procedures, case management, discharge, and clinical care systems.
• Advanced critical thinking and problem-solving skills for managing multiple levels of information and responsibilities.
• Advanced interpersonal and educational skills for collaborating with clinical-care professionals and providing education on coding, reimbursement, and documentation issues.
• Advanced ability to interpret and convey complex clinical and technical information both verbally and in writing.
• Advanced computer proficiency in relevant technology applications.
• Flexibility to orient for all patient populations across UCSF Health.
• In-depth understanding of SOI, ROM, HIM, ICD-10 coding, DRG system, regulatory requirements, and reimbursement processes.
• Organizational and project management skills for leading teams and prioritizing tasks.
• Certification as Clinical Documentation Specialist (CCDS).

About UCSF

The University of California, San Francisco (UCSF) is a leading institution dedicated to global health promotion. We foster a diverse community and engage in cutting-edge research, education, and patient care. UCSF is committed to equity in healthcare and workforce, aiming for a broadly diverse and inclusive community.

Equal Employment Opportunity

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, or protected veteran status.