UCSD Layoff from Career Appointment: Apply by 10/14/2019 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor.
Special Selection Applicants: Apply by 10/23/2019. Eligible Special Selection clients should contact their Disability Counselor for assistance.
The Clinical Documentation Specialist's 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. Face to face interaction and education with physicians and clinical staff. 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. Majority of chart reviews are done on the floors, telemetry or ICU wards.
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) (on the floors, telemetry or ICU wards). Establishes positive, professional, 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.
Bachelor's Degree in nursing (BSN) or related area; and/or equivalent combination of experience/training.
Acute care experience in adult ICU or Telemetry.
Three (3+) or more years of 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.
Strong interpersonal skills and ability to work with all levels of physicians, advanced practice providers and staff.
Experience as a Clinical Documentation Specialist.
Employment is subject to a criminal background check and pre-employment physical.
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.
UC San Diego is an academic powerhouse and economic engine, recognized as one of the top 8 public universities by U.S. News and World Report. Innovation is central to who we are and what we do. Here, students learn that knowledge isn't just acquired in the classroom - life is their laboratory. UC San Diego's rich academic portfolio includes six undergraduate colleges, five academic divisions and five graduate and professional schools. The university's award-winning scholars are experts at the forefront of their fields with an impressive track record for achieving scientific, medical and technological breakthroughs.