CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days HYBRID

UCI Health Clinical Documentation Specialist

UCI Health is one of California's largest academic health systems and the clinical enterprise of the University of California, Irvine. Established on July 1, 1976, UCI Health has grown into a 1,461-bed health system that includes UCI Health Orange, UCI Health Irvine, four Community Network hospitals and a growing network of ambulatory care centers across Orange and Los Angeles counties. As Orange County's only academic health systems, UCI Health is home to the only National Cancer Institute-designated comprehensive cancer center based in the county, the region's only American College of Surgeons-verified Level I adult and Level II pediatric trauma center, American College of Emergency Physicians Gold Level 1 Geriatric Emergency Department and a nationally recognized regional burn center verified by the American Burn Association. Powered by UC Irvine, UCI Health serves 5.6 million people across Orange County, western Riverside County and southeast Los Angeles County through excellence in patient care, research and medical education.

Your Role on the Team

Position Summary: The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.

What It Takes to be Successful

Required Qualifications: Strong clinical knowledge with ability to interpret clinical documentation Must possess the skill, knowledge and ability essential to the successful performance of assigned duties Must demonstrate customer service skills appropriate to the job Must be available for occasional weekend coverage Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics Five (5) or more years of clinical experience as either an RN or Physician and 3 years' experience in CDI Familiarity with Utilization Review criteria Familiarity of Joint Commission and CMS requirements Excellent written and verbal communication skills in English Critical thinking skills to problem solve and communicate with physicians on clinical issues CDI Credential (CCDS or CDIP) Bachelor of Science in Nursing or Medical School Graduate Ability to maintain a work pace appropriate to the workload Ability to influence and work collaboratively with physicians and all levels of staff Ability to establish and maintain effective working relationships across the Health System Preferred Qualifications: Previous experience with comprehensive chart / record review Master's degree with an emphasis in health care related fields (nursing, epidemiology, etc.) Knowledge of University and medical center organizations, policies, procedures and forms Experience working within EPIC and 3M 360 Encompass CAC CCS credential