Senior Clinical Documentation Specialist

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

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.