Clinical Documentation Specialist (CDI Expert)

UCSF Health, AG; Oakland (CA); Vor Ort; USD 90.000 - 120.000; Vollzeit

Zusammenfassung

UCSF Health is seeking a Clinical Documentation Specialist to evaluate physician documentation and ensure accuracy of illness severity and mortality risk in the medical record, improving coding quality. You will interact with physicians, clinical staff, and health information management professionals to align documentation with patient status.

Responsibilities include collaborating with coding staff to reflect discharge diagnoses and co-morbidities, supporting education on clinical documentation

Qualifikationen

• Bachelor's degree in nursing or related area is required.
• Five years of current/recent clinical experience in ICU/CCU/ED or Med Surg, or equivalent.
• Nuance pre-hire exam completed or eligible.
• Advanced knowledge of inpatient care processes, including diagnoses, treatments, coding, discharge planning, and reimbursement.

Aufgaben

• Evaluate physician documentation to ensure accurate severity of illness and risk of mortality reflection in the medical record for specificity and improved coding accuracy.
• Collaborate with physicians, clinical staff, and health information management professionals.
• Coordinate with coding staff to ensure documentation of discharge diagnoses and co-existing comorbidities reflects the patient’s clinical status.

Kenntnisse

Clinical documentation

Interdisciplinary collaboration

Critical thinking

Communication skills

Ausbildung

Bachelor's degree in nursing or related area

CA Nursing license

CCDS certification

Jobbeschreibung

UCSF Health is seeking a Clinical Documentation Specialist to evaluate physician documentation and ensure accuracy of illness severity and mortality risk in the medical record, improving coding quality. You will interact with physicians, clinical staff, and health information management professionals to align documentation with patient status.

Responsibilities include collaborating with coding staff to reflect discharge diagnoses and co-morbidities, supporting education on clinical documentation