Clinical Documentation Specialist 4 HX - Clinical Doc Integrity - P/T Days HYBRID

UCI Health is one of California’s largest academic health systems and the clinical enterprise of the University of California, Irvine. Established in 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. UCI Health serves 5.6 million people through excellence in patient care, research, and medical education.

Responsibilities

• Interpret clinical documentation with strong clinical knowledge
• Perform comprehensive chart and record reviews
• Apply knowledge of laws, rules, and regulations regarding appropriate clinical documentation, including coding guidelines and coding clinics
• Collaborate with physicians and staff to address clinical documentation issues
• Ensure compliance with Utilization Review criteria, Joint Commission, and CMS requirements
• Maintain a work pace appropriate to the workload
• Exercise discretion in managing sensitive information, including patient and employee records

Requirements

• Five (5) or more years of clinical experience as either an RN or Physician
• Three (3) years’ experience in Clinical Documentation Improvement (CDI)
• CDI Credential (CCDS or CDIP)
• Bachelor of Science in Nursing or Medical School Graduate
• Excellent written and verbal communication skills in English
• Critical thinking skills to problem solve and communicate with physicians on clinical issues
• 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
• Customer service skills appropriate to the job
• Availability for occasional weekend coverage

Preferred Qualifications

• Previous experience with comprehensive chart/record review
• Master’s degree with an emphasis in health care-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

• Medical insurance
• Sick and vacation time
• Retirement savings plans
• Access to a number of discounts and perks