Clinical Documentation Specialist (1 of 2)

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.

Reporting relationship: 

The Clinical Documentation Specialist (CDS’) reports to a CDI Manager under the leadership of the System Director of CDI. 

Department Description

Clinical Documentation Integrity (CDI) is a team within the Department of Quality that reviews provider documentation and facilitates accurate representation of patients treated at UCSF Health. Through collaborative relationships with Faculty service lines, CDI supports best practices in clinical documentation integrity strategies with an emphasis on severity of illness, medical complexity and quality in the medical record. CDI closely follows Case Mix Index (CMI), risk adjusted outcomes and mortality ratings.

%  

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

50

Conducts 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). Requires high level critical thinking and analytical skills related to conditions treated and evaluated at academic medical centers.  Requires precision and diligence for sustained efforts with attention to detail. Requires self reliance and ability to research clinical concepts.  Manages high volume case assignments, re-reviews and discharges. Highly specialized learning environment requires adaptability, flexibility, self-awareness and the ability to accept and apply constructive guidance. 

20

Establishes 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. Works on highly complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of  DRG (diagnosis-related groups) assignment.

10

Works closely with HIM coding staff to ensure that all clinical documentation is fully compliant and accurately reflects the patient's condition, treatments, and co-morbidities. Conducts reviews on specific cases involving mortalities, multiple complications for final outcomes with coding team. 

10

Analyzes highly complex data to identify trends, errors, inconsistencies, variances, or flags that may require an update to the documentation or coding. Recommends timely and effective strategies for revising codes or correcting clinical documentation to resolve problems and improve compliance.

10

Maintains current knowledge of best practices related to coding, diagnoses, treatment, and reimbursement. Serves as an expert resource to all levels of clinical staff and participates in the development of education shared with clinical teams and professional staff to achieve improved results in clinical documentation.

100%

REQUIRED QUALIFICATIONS

• Bachelor’s degree in nursing or related area, and/or equivalent combination of experience/training.
• This position requires 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. 

PREFERRED QUALIFICATIONS

• CA Nursing license
• Certification as Clinical Documentation Specialist (CCDS) 
• In-depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIM, ICD-10 coding, DRG system, standards of compliance, relevant Medicare Part A and Part B guidelines, and other reimbursement processes.
• Advanced knowledge of data collection, analysis, reporting techniques and systems, and of health care information related to clinical care, documentation, reporting, and reimbursement.

• Advanced organizational and project management skills, with the ability to lead a team, prioritize tasks, and see highly complex projects through from inception to completion on schedule.