Clinical Documentation Specialist — Elevate Records & Compliance

UCI Health; Orange (CA); On-site; USD 110,000 - 150,000; Full time

Job summary

UCI Health is seeking a Clinical Documentation Specialist to improve the quality, completeness, and accuracy of medical record documentation through comprehensive auditing and evaluation. You will proactively solicit clarification from physicians to ensure accurate data and reimbursement, educating staff on documentation guidelines and analyzing data to drive improvements.

Ideal candidates will have 5+ years of clinical experience (RN or medical) and 3+ years in CDI, with strong English

Qualifications

• Five or more years of clinical experience as either an RN or Physician and 3 years’ experience in CDI
• Strong clinical knowledge with ability to interpret clinical documentation
• Excellent written and verbal communication skills in English
• Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics
• Familiarity with Utilization Review criteria
• Familiarity of Joint Commission and CMS requirements
• CDI Credential (CCDS or CDIP)
• Bachelor of Science in Nursing or Medical School Graduate
• 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 demonstrate customer service skills appropriate to the job
• Must be available for occasional weekend coverage
• Ability to maintain a work pace appropriate to the workload

Responsibilities

• The Clinical Documentation Specialist improves the overall quality, completeness and accuracy of medical record documentation through auditing and evaluation.
• Educates others on documentation guidelines on an ongoing basis.
• Collects and analyzes data to provide reports and make recommendations.
• Proactively solicits clarification from physicians and other providers to ensure accurate quality data and appropriate reimbursement.

Skills

Strong clinical knowledge

Interpret clinical documentation

Customer service skills

Weekend coverage availability

Clinical documentation laws and coding

5+ years clinical experience (RN/Phys

Utilization Review criteria

Joint Commission & CMS requirements

Excellent English communication

Critical thinking

CDI credentials (CCDS/CDIP)

BSN or Medical School graduate

Work pace & workload management

Collaborative with physicians & staff

Interdepartmental relationship skills

Education

Bachelor of Science in Nursing or Medical School Graduate

Tools

EPIC

3M 360 Encompass CAC

Job description

UCI Health is seeking a Clinical Documentation Specialist to improve the quality, completeness, and accuracy of medical record documentation through comprehensive auditing and evaluation. You will proactively solicit clarification from physicians to ensure accurate data and reimbursement, educating staff on documentation guidelines and analyzing data to drive improvements.

Ideal candidates will have 5+ years of clinical experience (RN or medical) and 3+ years in CDI, with strong English