Clinical Documentation Specialist 4 HX - Clinical Doc Integrity - FT Days HYBRID

About the Organization

UCI Health is one of California's largest academic health systems and the clinical enterprise of the University of California, Irvine. Established on July 1, 1976, UCI Health has grown into a 1,461-bed health system that includes UCI Health - Orange, UCI Health - Irvine, four Community Network hospitals, and a growing network of ambulatory care centers across Orange and Los Angeles counties. As Orange County’s only academic health system, UCI Health is home to the only National Cancer Institute-designated comprehensive cancer center in the county, the region’s only American College of Surgeons-verified Level I adult and Level II pediatric trauma center, a Gold Level 1 Geriatric Emergency Department, and a nationally recognized regional burn center verified by the American Burn Association. Powered by UC Irvine, UCI Health serves 5.6 million people through excellence in patient care, research, and medical education.

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

• Interpret clinical documentation to ensure accuracy and completeness.
• Proactively solicit clarification from healthcare providers for further specificity in medical records.
• Educate others on documentation guidelines.
• Collect and analyze data to provide reports and recommendations.

Requirements

• Five (5) or more years of clinical experience as either an RN or Physician and 3 years’ experience in CDI.
• CDI Credential (CCDS or CDIP).
• Bachelor of Science in Nursing or Medical School Graduate.
• Strong clinical knowledge with the ability to interpret clinical documentation.
• Knowledge of laws, rules, and regulations regarding appropriate clinical documentation, including coding guidelines and coding clinics.
• Familiarity with Utilization Review criteria, 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.
• 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.
• Must be available for occasional weekend coverage.

Preferred Qualifications

• Previous experience with comprehensive chart/record review.
• Master’s degree with an emphasis in healthcare-related fields (nursing, epidemiology, etc.).
• Knowledge of University and medical center organizations, policies, procedures, and forms.
• Experience working within EPIC and 3M 360 Encompass CAC.
• CCS credential.

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.

Conditions of Employment

• Background Check and Live Scan.
• Employment Misconduct disclosure requirement.
• Legal Right to Work in the United States.
• Vaccination Policies compliance.
• Smoking and Tobacco Policy compliance.
• Drug-Free Environment compliance.
• Additional conditions may apply, including California Child Abuse and Neglect Reporting Act, E-Verify, and Pre-Placement Health Evaluation.