Clinical Documentation Specialist

Job Description

This role entails evaluating physician documentation with the application of clinical expertise to ensure accurate representation of patient severity of illness and mortality risk in medical records. The specialist collaborates with physicians, clinical personnel, and health information management teams to guarantee that discharge diagnoses and co-morbid conditions fully reflect patient clinical status and care.

Department Overview

The Clinical Documentation Specialist (CDS) operates under the CDI Manager within the Department of Quality. The Clinical Documentation Integrity (CDI) team reviews provider documentation to ensure precise articulation of patient care at UCSF Health. This team partners with faculty service lines, emphasizing documentation integrity, severity of illness, medical complexity, and medical record quality. They closely monitor Case Mix Index (CMI), risk-adjusted outcomes, and mortality data.

Key Responsibilities

• Perform concurrent reviews of complex patient cases to assess quality, consistency, completeness, and accuracy of clinical documentation related to severity of illness (SOI) and risk of mortality (ROM), requiring advanced critical thinking and thorough research of clinical concepts.
• Develop cooperative relationships with clinicians, patient care staff, HIM, coding personnel, and other relevant managers to identify and address documentation gaps and ensure appropriate diagnosis-related group (DRG) assignments.
• Collaborate with coding teams to assure clinical documentation compliance and accuracy, focusing on cases with mortalities or multiple complications.
• Analyze complex data sets to detect documentation or coding errors and propose timely corrective strategies to improve compliance.
• Maintain up-to-date expertise on best practices relating to coding, diagnoses, treatments, and reimbursement, providing education and guidance for clinical and professional teams.

Qualifications

• At least five years of recent clinical experience in intensive care units (ICU, CCU), emergency departments (ED), medical-surgical units, or a combination of education and experience.
• Bachelor's degree in nursing or a related discipline, or equivalent experience/training.
• Successful completion of Nuance pre-employment examination.
• Advanced knowledge of inpatient care clinical and operational protocols, including diagnosis, treatment, medical procedures, case management, and discharge processes.
• Strong critical thinking and problem-solving skills to handle complex clinical information and responsibilities efficiently.
• Excellent interpersonal and educational abilities to collaborate and convey coding, reimbursement, and clinical documentation matters effectively.
• Proficient in interpreting complex clinical and technical data and delivering clear presentations and reports.
• Capability to work collaboratively with senior staff across departments, providing expert counsel on clinical quality, technology use, and documentation efficiency.
• High computer literacy with multiple relevant technology applications.
• Flexibility to adapt across all patient populations at UCSF Health.

• Preferred qualifications:
• Thorough understanding of clinical documentation accuracy, medical record review, SOI, ROM, HIM standards, ICD-10 coding, DRG systems, compliance standards, and Medicare guidelines.
• Advanced skills in data collection, analysis, and reporting related to clinical care, documentation, and reimbursement.
• Strong organizational and project management capabilities with demonstrated leadership in complex projects.
• California nursing license.
• Certification as a Clinical Documentation Specialist (CCDS).

About UCSF

The University of California, San Francisco (UCSF) is a premier institution devoted to advancing global health through biomedical research, graduate education in health sciences, and excellent patient care. It is the sole UC campus focused entirely on health sciences, housing five Nobel laureates and pioneering breakthroughs in cancer, aging, neurodegenerative diseases, and stem cell research.

Values and Commitment

UCSF values professionalism, respect, integrity, diversity, and excellence (PRIDE values). It embraces equity in care delivery and workforce inclusivity, fostering a culturally competent, welcoming community fueled by diverse perspectives.

Equal Employment Opportunity

UCSF is an Equal Opportunity Employer committed to providing workplace fairness and diversity, considering all qualified applicants without regard to race, gender, sexual orientation, disability, age, veteran status, or other protected categories under law.

Salary Information

Compensation is determined based on experience and internal equity, subject to policy approvals. For union-represented roles, salary positioning follows collective bargaining agreements.

Additional Information

Visit the UCSF benefits site for comprehensive details on total compensation and benefits.