CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days HYBRID
About the role
The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.
Responsibilities
- Facilitate improvement in the overall quality, completeness and accuracy of medical record documentation
- Proactively solicit clarification from physicians and other healthcare providers when further specificity is needed
- Educate others on documentation guidelines on an ongoing basis
- Collect and analyze data to provide reports and make recommendations
Requirements
- Strong clinical knowledge with ability to interpret clinical documentation
- Possess the skill, knowledge and ability essential to the successful performance of assigned duties
- Demonstrate customer service skills appropriate to the job
- Available for occasional weekend coverage
- Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics
- Familiarity with Utilization Review criteria
- Familiarity of Joint Commission and CMS requirements
- Excellent written and verbal communication skills in English
- Critical thinking skills to problem solve and communicate with physicians on clinical issues
- CDI Credential (CCDS or CDIP)
- Bachelor of Science in Nursing or Medical School Graduate
- Able to maintain a work pace appropriate to the workload
- Able to influence and work collaboratively with physicians and all levels of staff
- Able to establish and maintain effective working relationships across the Health System
Qualifications
- Five (5) or more years of clinical experience as either an RN or Physician
- Three (3) years’ experience in CDI
- Familiarity with Utilization Review criteria
- Familiarity of Joint Commission and CMS requirements
- Excellent written and verbal communication skills in English
- Critical thinking skills to problem solve and communicate with physicians on clinical issues
- CDI Credential (CCDS or CDIP)
- Bachelor of Science in Nursing or Medical School Graduate
- Able to maintain a work pace appropriate to the workload
- Able to influence and work collaboratively with physicians and all levels of staff
- Able to establish and maintain effective working relationships across the Health System
Skills
- Strong clinical knowledge with ability to interpret clinical documentation
- Possess the skill, knowledge and ability essential to the successful performance of assigned duties
- Demonstrate customer service skills appropriate to the job
- Available for occasional weekend coverage
- Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics
- Familiarity with Utilization Review criteria
- Familiarity of Joint Commission and CMS requirements
- Excellent written and verbal communication skills in English
- Critical thinking skills to problem solve and communicate with physicians on clinical issues
- CDI Credential (CCDS or CDIP)
- Bachelor of Science in Nursing or Medical School Graduate
- Able to maintain a work pace appropriate to the workload
- Able to influence and work collaboratively with physicians and all levels of staff
- Able to establish and maintain effective working relationships across the Health System
Benefits
We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.
Pay
Details of each policy may be reviewed by visiting the following page: Conditions of Employment
Schedule
Details of each policy may be reviewed by visiting the following page: Conditions of Employment