Senior Clinical Documentation Specialist – CDI Expert

University-of-California,-Irvin; Irvine (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

UCI Health is seeking a Clinical Documentation Specialist to enhance the quality and accuracy of medical record documentation through comprehensive auditing, analysis, and education. You will solicit clarifications from physicians to ensure precise data and appropriate reimbursement, and generate actionable reports for improvement.

Ideal candidates will have 5+ years of clinical experience as RN/Physician, 3+ years in CDI, and CDI credentials, with strong knowledge of coding guidelines and

Qualifications

• Five or more years of clinical experience as either an RN or Physician and 3 years’ experience in CDI.
• Knowledge of laws, rules and regulations regarding clinical documentation including coding guidelines and coding clinics.
• Excellent written and verbal communication skills in English.
• Familiarity with Utilization Review criteria.
• Familiarity with Joint Commission and CMS requirements.

Responsibilities

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through auditing and evaluation of the medical record.
• Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement.
• Educates others on documentation guidelines on an ongoing basis.
• Collects and analyzes data to provide reports and make recommendations.

Skills

Strong clinical knowledge

Customer service

English communication

Coding guidelines

CDI Credential

Education

Bachelor of Science in Nursing or Medical School Graduate

CDI Credential (CCDS or CDIP)

CCS credential

Tools

EPIC

3M 360 Encompass CAC

Job description

UCI Health is seeking a Clinical Documentation Specialist to enhance the quality and accuracy of medical record documentation through comprehensive auditing, analysis, and education. You will solicit clarifications from physicians to ensure precise data and appropriate reimbursement, and generate actionable reports for improvement.

Ideal candidates will have 5+ years of clinical experience as RN/Physician, 3+ years in CDI, and CDI credentials, with strong knowledge of coding guidelines and