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. Powered by UC Irvine, UCI Health serves 5.6 million people through excellence in patient care, research, and medical education.

Responsibilities

• Interpret clinical documentation to ensure accuracy and compliance with coding guidelines and coding clinics
• Apply knowledge of laws, rules, and regulations regarding appropriate clinical documentation
• Perform comprehensive chart and record reviews
• Communicate with physicians on clinical issues using critical thinking and problem-solving skills
• Collaborate with physicians and all levels of staff to influence and improve clinical documentation
• 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 records, financial data, and strategic plans
• Safeguard sensitive information and follow data protection and privacy policies

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
• Strong clinical knowledge and ability to interpret clinical documentation
• Excellent written and verbal communication skills in English
• Customer service skills appropriate to the job
• Availability for occasional weekend coverage
• Ability to establish and maintain effective working relationships across the Health System

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

Conditions of Employment

All applicants who accept an offer of employment must comply with the following:

• Background Check and Live Scan
• Employment Misconduct Disclosure (final candidate must disclose any administrative or judicial decisions, allegations, or investigations involving misconduct within the last seven years)
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug-Free Environment
• Exercise utmost discretion in managing sensitive information, including secure handling of physical and digital records

Additional conditions may apply based on business unit or job-specific requirements, including California Child Abuse and Neglect Reporting Act, E-Verify, and Pre-Placement Health Evaluation.