Job Description

Clinical Documentation Specialist

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive 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.

Required 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
• Ability to maintain a work pace appropriate to the workload
• 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

Preferred Qualifications:

• Previous experience with comprehensive chart / record review
• Master's degree with an emphasis in health care related fields (nursing, epidemiology, etc.)
• Knowledge of University and medical center organizations, policies, procedures and forms
• Experience working within EPIC and 3M 360 Encompass CAC
• CCS credential

Total Rewards

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.

Conditions of Employment:

• Background Check and Live Scan
• Employment Misconduct*
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment

*Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.

• California Child Abuse and Neglect Reporting Act
• E-Verify
• Pre-Placement Health Evaluation

Details of each policy may be reviewed by visiting the following page:

Closing Statement:

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected categories covered by the UC Anti-Discrimination Policy. We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable, and welcoming. UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI's Employee Experience Center (EEC) at eec@uci.edu or at (949) 824-0500, Monday - Friday from 8:30 a.m. - 5:00 p.m.

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