CLIN DOC SPEC 3 HX

UCSF Health; San Francisco (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

UCSF Health in San Francisco seeks a Clinical Documentation Specialist to evaluate physician documentation and ensure accurate representation of severity of illness and risk of mortality in the medical record.

You will collaborate with physicians, clinical staff, and health information management professionals, aligning discharge diagnoses and co-morbidities with the patient’s clinical status while supporting compliant reimbursement.

Qualifications

• Thorough knowledge of inpatient care, including diagnoses, treatments, co-morbidities, discharge, and other practices that are part of effective clinical care systems.
• Thorough understanding of SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, Medicare Part A/B guidelines and reimbursement processes.
• Thorough knowledge of data collection, analysis, reporting techniques and health care information management systems.
• Detail oriented, with proven organizational skills and ability to manage time, prioritize tasks, and see complex projects through to completion.

Responsibilities

• Evaluate physician documentation to ensure accuracy of severity of illness and risk of mortality in the medical record.
• Interact with physicians, clinical staff, and health information management professionals to align documentation with clinical status and care.
• Collaborate with coding staff to ensure discharge diagnoses and co-existing co-morbidities reflect the patient’s clinical status.

Skills

Clinical documentation

Interprofessional collaboration

Critical thinking

Problem solving

Data analysis

Presentation skills

Education

Bachelor's degree in PT/OT/SPT

Job description

Job Function Summary:

Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.

Job Description

Job Function Summary

Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.

Generic Scope

Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.

Custom Scope

Applies skills and experience as a seasoned clinical documentation specialist to projects of medium size at all levels of complexity, or portions of large projects.

Qualifications

Knowledge, Skills and Abilities Req / Pref

Thorough knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, complications, co-morbidities, discharge, and other practices that are part of effective clinical care systems. Req

Thorough understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes. Req

Thorough knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement. Req

Detail oriented, with proven organizational skills and the ability to effectively manage time, prioritize tasks, and see complex projects through to completion on schedule. Req

Strong critical-thinking and problem solving skills to manage multiple levels of information and responsibilities, and quickly assess complex problems to develop multiple potential solutions. Req

Strong interpersonal and educational skills, with the ability to collaborate effectively with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues. Req

Proven ability to interpret and effectively convey complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports. Req

Strong ability to work with senior staff and managers across departments and to provide advice and recommendations on complex issues of functionality, clinical quality, efficiency, and program development. Req

Proven computer proficiency in relevant multiple technology applications. Req

3 years related work experience Req

Education

Req / Pref

Bachelor's degree in PT/OT/SPT

Required

About Us

About UCSF

The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world’s leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells.

Pride Values

UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence – also known as our PRIDE values.

In addition to our PRIDE values, UCSF is committed to equity – both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available here .

Join us to find a rewarding career contributing to improving healthcare worldwide.

Equal Employment Opportunity

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.

Salary Information

The final salary and offer components are subject to additional approvals based on UC policy.

Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.

To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html