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About the Role
The Clinical Documentation Specialist (CDS) role involves evaluating physician documentation using clinical expertise to ensure accurate portrayal of patient severity of illness and risk of mortality for improved coding accuracy. This role collaborates with physicians, clinical staff, and health information management professionals to ensure the medical record fully reflects the patient's clinical status and care.
Responsibilities
- Conduct timely concurrent case reviews of clinical documentation in highly complex cases, evaluating quality, consistency, completeness, and accuracy for severity of illness (SOI) and risk of mortality (ROM).
- Manage high volume case assignments, re-reviews, and discharges.
- Establish collaborative working relationships with clinicians, patient care professionals, health information management (HIM), and coding staff, as well as managers in clinical, quality, and information technology.
- Identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment on highly complex cases.
- Work closely with HIM coding staff to ensure clinical documentation accurately reflects the patient's condition, treatments, and co-morbidities.
- Conduct reviews on specific cases involving mortalities, multiple complications for final outcomes with the coding team.
- Analyze highly complex data to identify trends, errors, inconsistencies, variances, or flags that may require an update to the documentation or coding.
- Recommend strategies for revising codes or correcting clinical documentation to resolve problems and improve compliance.
- Maintain current knowledge of best practices related to coding, diagnoses, treatment, and reimbursement.
- Serve as an expert resource to all levels of clinical staff.
- Participate in the development of education shared with clinical teams and professional staff to achieve improved results in clinical documentation.
Requirements
- Bachelor’s degree in nursing or related area, and/or equivalent combination of experience/training.
- Flexibility to orient to all patient populations across UCSF Health.
- Five years of current/recent clinical experience working in ICU, CCU, ED, or Med Surg, or a combination of education and experience.
- Successful completion of Nuance pre-hire exam.
- Advanced knowledge and experience with the clinical and operational issues involved with inpatient care, including diagnoses, treatments, medical procedures, case management, discharge, and other practices that are part of effective clinical care systems.
- Advanced critical thinking and problem-solving skills to manage multiple levels of information and responsibilities and quickly assess highly complex problems to develop an expedient path of resolution.
- Advanced interpersonal and educational skills, with the ability to collaborate effectively on highly complex projects with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues.
- Advanced ability to interpret and effectively convey highly complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports.
- In-depth ability to collaborate effectively with senior staff and management across departments and to provide counsel and guidance on highly complex issues of functionality, clinical quality, efficiency, and proficiency in relevant multiple technology applications.
- Advanced computer proficiency in relevant multiple technology applications.
Skills
- Clinical expertise
- Critical thinking
- Analytical skills
- Diligence
- Attention to detail
- Self-reliance
- Research clinical concepts
- Adaptability
- Flexibility
- Self-awareness
- Interpersonal skills
- Educational skills
- Communication skills (verbal and written)
- Presentation skills
- Reporting skills
- Computer proficiency
Location
- UCSF Health
Work Type
- Full-time
Experience Level
- 5 years of current/recent clinical experience
- Advanced knowledge and experience
Education Level
- Bachelor’s degree in nursing or related area
- Certification as Clinical Documentation Specialist (CCDS)
Benefits
- Total compensation information available at https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html
About the Company
- The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.
- UCSF is the only campus in the 10-campus UC system dedicated exclusively to the health sciences.
- UCSF brings together the world’s leading experts in nearly every area of health.
- UCSF is home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells.
- UCSF is a diverse community made of people with many skills and talents.
- UCSF is committed to professionalism, respect, integrity, diversity and excellence – also known as our PRIDE values.
- UCSF is committed to equity – both in how we deliver care as well as our workforce.
- UCSF is committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care.
Equal Opportunity
- 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 status under state or federal law.