(RN/MD) Clinical Documentation Specialist - 118535
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#118535 (RN/MD) Clinical Documentation SpecialistInitial Review Date: Fri 9/16/2022
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 and influenza before they will be allowed on campus or in a facility or office. For more information visit: Flu Vaccine Mandate / COVID Vaccine Policy
UCSD Layoff from Career Appointment: Apply by 8/31/2022 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.
Special Selection Applicants: Apply by 9/9/2022. 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.
- 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 an active CCDS/CDIP certification.
This position is not remote. Positions are on-site, face-to-face, and during normal business hours (days) Monday-Friday.
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.
Demonstrated adult ICU or Telemetry work experience.
Effective 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 (CCDS) or Certified Documentation Improvement Practitioner (CDIP).
- The salary for this position is $100,000-130,000. Those with no prior work experience as a CDS will be placed around $100,000-105,000. Those with prior CDS work experience will be placed around $105,000-130,000 commensurate with CDS experience.
- 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 14 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).
If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.
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, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!
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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: http://www-hr.ucsd.edu/saa/nondiscr.html
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