(RN/MD) Clinical Documentation Specialist - 137982
University of California San Diego, San Diego, California, United States, 92189
DESCRIPTION OVERVIEW
RN or physician with inpatient hospital experience in Tele or ICU seeking an administrative role that capitalizes on clinical documentation experience. The Clinical Documentation Specialist role involves evaluation of physician documentation to ensure that patient severity of illness (SOI) and risk of mortality (ROM) 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 discharge diagnoses and co-existing co-morbidities reflect the patient\'s clinical status and care. KEY RESPONSIBILITIES
Performs complex reviews of patient documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for SOI and ROM. Establishes productive working relationships with clinicians, patient care staff, HIM, and coding personnel; identifies documentation gaps and ensures appropriateness of DRG assignment. Collaborates with HIM coding staff to ensure discharge documentation reflects the patient\'s condition, treatments, and co-morbidities. Participates in medical record reviews on cases involving mortalities, complications, and other situations requiring secondary reviews. Analyzes complex clinical data to identify trends, errors, inconsistencies, variances, or red flags delaying third-party reimbursement. Recommends strategies for revising or correcting clinical documentation to improve compliance. Monitors changes in regulatory requirements for clinical documentation. Reviews inpatient records for appropriateness and compliance with federal, state, and other regulatory requirements. Maintains knowledge of ICD-10 guidelines, DRG systems, and reimbursement issues. Serves as an educational resource to clinical staff and contributes to curriculum development for trainings to achieve improved results in clinical documentation and reimbursement. Other duties as assigned. COMPENSATION AND WORK ENVIRONMENT
Hiring Pay Scale: $100,000 - $200,000 per year. Worksite: La Jolla. Appointment Type: Career. Appointment Percent: 100%. Union: HX Contract. Total Openings: 1. Work Schedule: Days, 8 hrs/day, Monday - Friday. This position is not remote; on-site, with duties as assigned. OPENING STATUS
This posting will remain open until all vacancies have been filled. About extended deadlines and application details: apply by the extended deadline if stated. MINIMUM QUALIFICATIONS
Seven (7+) or more years of relevant inpatient clinical experience OR three (3+) or more years with a bachelor\'s degree in nursing or related area. Experience with clinical and operational issues involved with inpatient care, including diagnoses, treatments, procedures, complications, co-morbidities, discharge, and related practices. Professional work experience as Clinical Documentation Specialist. If insufficient pool, clinicians (RNs or MDs) with three (3+)+ years of experience in acute adult Telemetry and/or ICU may be considered. Demonstrated adult ICU or Telemetry work experience. Effective interpersonal skills and ability to work with all levels of physicians and staff. PREFERRED QUALIFICATIONS
MSN or other Master\'s degree. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP). SPECIAL CONDITIONS
The hiring salary range for Clinical Documentation Specialist 3 is $97,200-182,000; for Clinical Documentation Specialist 4 is $119,400-230,800, commensurate with experience. Level 4 requires active CCDS/CDIP certification. Must be able to work various hours and locations based on business needs. Must be onsite full time Mon-Fri. Position primarily in La Jolla, with possible work at Hillcrest and East Campus. Employment is subject to a criminal background check and pre-employment physical. BENEFITS / ADDITIONAL INFORMATION
Our employees enjoy competitive compensation packages and full benefits on day of hire, including health/dental/vision insurance, vacation, sick leave, holidays, UC Retirement Plan, and other perks. The posting may include pay transparency information and notes about pay ranges and eligibility criteria. Pay Transparency Act: Annual Full Pay Range: Unclassified - No data available (prorated if appointment percentage
ADDITIONAL NOTES
Vaccination compliance may be required. If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment. UC San Diego Health is an equal opportunity employer and is dedicated to a diverse and inclusive environment. Misconduct disclosure requirements apply for final candidates. For more information, refer to UC policies and community statements.
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RN or physician with inpatient hospital experience in Tele or ICU seeking an administrative role that capitalizes on clinical documentation experience. The Clinical Documentation Specialist role involves evaluation of physician documentation to ensure that patient severity of illness (SOI) and risk of mortality (ROM) 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 discharge diagnoses and co-existing co-morbidities reflect the patient\'s clinical status and care. KEY RESPONSIBILITIES
Performs complex reviews of patient documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for SOI and ROM. Establishes productive working relationships with clinicians, patient care staff, HIM, and coding personnel; identifies documentation gaps and ensures appropriateness of DRG assignment. Collaborates with HIM coding staff to ensure discharge documentation reflects the patient\'s condition, treatments, and co-morbidities. Participates in medical record reviews on cases involving mortalities, complications, and other situations requiring secondary reviews. Analyzes complex clinical data to identify trends, errors, inconsistencies, variances, or red flags delaying third-party reimbursement. Recommends strategies for revising or correcting clinical documentation to improve compliance. Monitors changes in regulatory requirements for clinical documentation. Reviews inpatient records for appropriateness and compliance with federal, state, and other regulatory requirements. Maintains knowledge of ICD-10 guidelines, DRG systems, and reimbursement issues. Serves as an educational resource to clinical staff and contributes to curriculum development for trainings to achieve improved results in clinical documentation and reimbursement. Other duties as assigned. COMPENSATION AND WORK ENVIRONMENT
Hiring Pay Scale: $100,000 - $200,000 per year. Worksite: La Jolla. Appointment Type: Career. Appointment Percent: 100%. Union: HX Contract. Total Openings: 1. Work Schedule: Days, 8 hrs/day, Monday - Friday. This position is not remote; on-site, with duties as assigned. OPENING STATUS
This posting will remain open until all vacancies have been filled. About extended deadlines and application details: apply by the extended deadline if stated. MINIMUM QUALIFICATIONS
Seven (7+) or more years of relevant inpatient clinical experience OR three (3+) or more years with a bachelor\'s degree in nursing or related area. Experience with clinical and operational issues involved with inpatient care, including diagnoses, treatments, procedures, complications, co-morbidities, discharge, and related practices. Professional work experience as Clinical Documentation Specialist. If insufficient pool, clinicians (RNs or MDs) with three (3+)+ years of experience in acute adult Telemetry and/or ICU may be considered. Demonstrated adult ICU or Telemetry work experience. Effective interpersonal skills and ability to work with all levels of physicians and staff. PREFERRED QUALIFICATIONS
MSN or other Master\'s degree. Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP). SPECIAL CONDITIONS
The hiring salary range for Clinical Documentation Specialist 3 is $97,200-182,000; for Clinical Documentation Specialist 4 is $119,400-230,800, commensurate with experience. Level 4 requires active CCDS/CDIP certification. Must be able to work various hours and locations based on business needs. Must be onsite full time Mon-Fri. Position primarily in La Jolla, with possible work at Hillcrest and East Campus. Employment is subject to a criminal background check and pre-employment physical. BENEFITS / ADDITIONAL INFORMATION
Our employees enjoy competitive compensation packages and full benefits on day of hire, including health/dental/vision insurance, vacation, sick leave, holidays, UC Retirement Plan, and other perks. The posting may include pay transparency information and notes about pay ranges and eligibility criteria. Pay Transparency Act: Annual Full Pay Range: Unclassified - No data available (prorated if appointment percentage
ADDITIONAL NOTES
Vaccination compliance may be required. If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment. UC San Diego Health is an equal opportunity employer and is dedicated to a diverse and inclusive environment. Misconduct disclosure requirements apply for final candidates. For more information, refer to UC policies and community statements.
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