Job Description

Payroll Title:
Salary Range
Commensurate with Experience
La Jolla Medical Center
Appointment Type:
Appointment Percent:
Total Openings:
Work Schedule:
Days, 8 hours, Monday-Friday

As a federally-funded institution, UC San Diego Health maintains a marijuana and drug free campus. New employees are subject to drug screening.

#111293 (RN/MD) Clinical Documentation Specialist

Extended Deadline: Fri 9/24/2021

For the safety and well-being of the entire university community, the University of California requires, with few exceptions, that all students, faculty and staff be vaccinated against the COVID-19 virus before they will be allowed on campus or in a facility or office. For more information visit:

UCSD Layoff from Career Appointment: Apply by 8/25/2021 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.

Special Selection Applicants: Apply by 9/3/2021. Eligible Special Selection clients should contact their Disability Counselor for assistance.


Are you an RN or physician with inpatient hospital experience in Tele or ICU seeking an administrative role that capitalizes on your clinical documentation experience? This job is for you!

The Clinical Documentation Specialist role involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

Key Responsibilities:

  • Performs complex reviews of patient’s medical documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).
  • Establishes productive working relationships in regular communications with clinicians, patient care staff, and health information management (HIM), and coding personnel, working on complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment.
  • Collaborates with HIM coding staff to ensure that all clinical documentation at discharge is compliant and accurately reflects the patient's condition, treatments, and any co-morbidities.
  • Participates in medical record reviews on specific cases involving mortalities, complications, and other situations requiring secondary reviews.
  • Analyzes complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement.
  • Recommends timely and effective strategies for revising or correcting clinical documentation to resolve problems and improve compliance.
  • Monitors changes and updates in regulatory requirements for clinical documentation.
  • Reviews and analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.
  • Maintains current knowledge of ICD-10 coding guidelines, DRG systems, and reimbursement issues.
  • Serves as an educational resource to all levels of clinical staff and contributes to the development of curriculum for in service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement.
  • Other duties as assigned.

Depending on CDS experience and qualifications of the selected candidate, this position will be hired at the professional level 3 or level 4. The professional level 4 requires at minimum a CDS certification.

Positions are onsite, face-to-face, and during normal business hours Monday-Friday. This position is not remote.

While not required, a cover letter is highly recommended when applying to this position.


  • Seven (7) or more years of relevant inpatient clinical experience OR three (3) or more years of relevant inpatient clinical experience and a bachelor's degree in nursing or related area.

  • Experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, complications, co-morbidities, discharge, and other practices that are part of effective clinical care systems.

  • Professional work experience as Clinical Documentation Specialist. If insufficient application pool, department may consider clinicians (RNs or MDs) with three (3) or more years of experience in acute adult Telemetry and/or ICU.

  • Adult ICU or Telemetry work experience.

  • Interpersonal skills and ability to work with all levels of physicians, advanced practice providers and staff.


  • MSN or other Master’s degree.

  • Certified Clinical Documentation Specialist.


  • Must be able to work various hours and locations based on business needs.

  • Must be able to work onsite throughout UC San Diego Health’s facilities full time Mon-Fri, duties as assigned.

  • This position is located primarily in La Jolla, but may need to work in Hillcrest based on business needs.

  • Employment is subject to a criminal background check and pre-employment physical.

UC San Diego Health was recently recognized as sixth among the top academic medical centers in the U.S. for excellence in delivering high-quality care. The ranking is based on the Vizient Quality and Accountability dashboard which measures safety, mortality, clinical effectiveness, efficiency and patient centeredness.

Our employees enjoy competitive compensation packages in a diverse, stimulating workforce. These positions are eligible for full benefits first day of hire, including but not limited to:
* Health/Dental/Vision insurance
* 15 vacation days, 12 sick days, and 13 paid holidays per year
* Work life balance
* UC Retirement Plan
* Pet insurance

Job offer is contingent on successful engagement in the UC COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, and several outpatient clinics. UC San Diego Medical Center in Hillcrest is a designated Level I Trauma Center and has the only Burn Center in the county. We invite you to join our dynamic team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

UC San Diego Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity or sexual orientation. For the complete University of California nondiscrimination and affirmative action policy see:

UC San Diego is a smoke and tobacco free environment. Please visit for more information.

Application Instructions

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