Senior Clinical Documentation Specialist – CDI Expert

University of California - Irvine Health; Orange (CA); On-site; USD 90,000 - 130,000; Full time

Job summary

University of California - Irvine Health seeks a Clinical Documentation Specialist to improve the quality and accuracy of medical record documentation. You will audit records, solicit physician clarification, and educate staff on documentation guidelines to ensure accurate data and appropriate reimbursement.

Requires 5+ years of clinical experience as RN or Physician, 3 years CDI, CCDS/CDIP, and strong English communication. EPIC and 3M 360 Encompass CAC experience preferred.

Qualifications

• Strong clinical knowledge with ability to interpret clinical documentation.
• Must possess the skill, knowledge and ability essential to the successful performance of assigned duties.
• Must demonstrate customer service skills appropriate to the job.
• Must be available for occasional weekend coverage.
• Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics.
• Five (5) or more years of clinical experience as either an RN or Physician and 3 years' experience in CDI.
• Familiarity with Utilization Review criteria.
• Familiarity of Joint Commission and CMS requirements.
• Excellent written and verbal communication skills in English.
• Critical thinking skills to problem solve and communicate with physicians on clinical issues.
• CDI Credential (CCDS or CDIP).
• Bachelor of Science in Nursing or Medical School Graduate.

Responsibilities

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

Skills

Clinical documentation

Customer service

Communication

Critical thinking

Education

BSN or MD

Tools

EPIC

3M 360 Encompass CAC

Job description

University of California - Irvine Health seeks a Clinical Documentation Specialist to improve the quality and accuracy of medical record documentation. You will audit records, solicit physician clarification, and educate staff on documentation guidelines to ensure accurate data and appropriate reimbursement.

Requires 5+ years of clinical experience as RN or Physician, 3 years CDI, CCDS/CDIP, and strong English communication. EPIC and 3M 360 Encompass CAC experience preferred.