CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days REMOTE
Position Summary
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.
About the role
- Facilitate improvement in medical record documentation quality
- Evaluate medical records for completeness and accuracy
- Solicit clarification from healthcare providers as needed
- Educate others on documentation guidelines
- Analyze data to provide reports and recommendations
Responsibilities
- Comprehensive auditing and evaluation of medical records
- Proactively solicit clarification from physicians and other healthcare providers
- Educate others on documentation guidelines
- Collect and analyze data to provide reports and recommendations
Requirements
- Strong clinical knowledge with ability to interpret clinical documentation
- 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 with 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
- Ability to maintain a work pace appropriate to the workload
- Ability to influence and work collaboratively with physicians and all levels of staff
- Ability to establish and maintain effective working relationships across the Health System
Qualifications
- Strong clinical knowledge with ability to interpret clinical documentation
- 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 with 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
- Ability to maintain a work pace appropriate to the workload
- Ability to influence and work collaboratively with physicians and all levels of staff
- Ability to establish and maintain effective working relationships across the Health System
Skills
- Strong clinical knowledge
- Interpret clinical documentation
- Clarify medical records
- Educate on documentation guidelines
- Analyze data
- Problem solve with physicians
- Excellent written and verbal communication skills
- Critical thinking skills
- CDI Credential (CCDS or CDIP)
- Strong clinical experience
- Experience in CDI
- Familiarity with Utilization Review criteria
- Familiarity with Joint Commission and CMS requirements
- Ability to maintain a work pace
- Ability to influence and work collaboratively
- Ability to establish and maintain effective working relationships
Benefits
Details of benefits can be found here.
Pay
Details of pay can be found here.
Schedule
Details of schedule can be found here.
Contact Information
If you have questions, please contact UCI's Employee Experience Center at eec@uci.edu or at (949) 824-0500, Monday - Friday from 8:30 a.m. - 5:00 p.m.