Remote Clinical Documentation Specialist (RN) – California

Job Summary

The Clinical Documentation Specialist (CDS) facilitates accurate documentation of the severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff.  Active participation in team meetings and staff education on standard CDI processes and software are keys to the role.

The final salary and offer components are subject to additional approvals based on UC policy.

To see the salary range for this position (we recommend that you make a note of the job code and use that to look up): TCS Non-Academic Titles Search (ucop.edu)

Please note: An offer will take into consideration the experience of the final candidate AND the current salary level of individuals working at UCSF in a similar role.

For roles covered by a bargaining unit agreement, there will be specific rules about where a new hire would be placed on the range.

To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html

Department Description

Clinical Documentation Integrity (CDI) is a unit of the Department of Quality that reviews provider documentation for accurate representation of patients treated across UCSF Health. Through collaborative relationships with clinical service lines, CDI supports best practices in clinical documentation to improve accuracy in quality metrics that best represent our patients’ severity of illness, medical complexity, and associated care. CDI closely follows the Case mix index, risk-adjusted outcomes, and Mortality ratings.

Required Qualifications

• Bachelor’s degree or higher in a healthcare-related field (i.e., Bachelor of Science in Nursing, Master of Science in Nursing, Medical Doctor, Master of Public Health)
• Five years of current/recent clinical experience working in Pediatric Intensive Care Unit, Cardiac Care Unit, Emergency Department, or Med Surgery 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 the 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 complex projects with clinical-care professionals and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues.
• Advanced skills in written and verbal communications, with the ability to interpret and convey complex clinical and technical information in a clear, concise manner 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 program development.
• Computer proficiency in relevant multiple technology applications.

Preferred Qualifications

• Active CA RN license
• Certification as a Clinical Documentation Specialist (CCDS) or Coding certification (ie, Certified Documentation Improvement Practitioner or  Certified Coding Specialist)
• 1-2 years of Clinical Documentation Improvement or Quality Improvement experience, preferably at a large Academic Medical Center.
• In-depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including Severity of Illness, Risk of Mortality, HIMS, ICD-10 coding, diagnostic-related group systems, standards of compliance, relevant Medicare Part A and Part B guidelines, and other reimbursement processes.
• Advanced knowledge of data collection, analysis, and reporting techniques and systems, and of health care information management systems 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.

About UCSF

At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what’s possible for the patients we serve – a promise we share with the professionals who make up our team.

Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report – UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents.

Pride Values

UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence – also known as our PRIDE values.

In addition to our PRIDE values, UCSF is committed to equity – both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at diversity.ucsf.edu

Join us to find a rewarding career contributing to improving healthcare worldwide.

Equal Employment Opportunity

The University of California San Francisco is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Organization

Health

Job Code and Payroll Title

006484 CLIN DOC SPEC 4

Job Category

Professional (Non-Clinical)

Bargaining Unit

99 – Policy-Covered (No Bargaining Unit)

Employee Class

Career

Percentage

100%

Location

Remote / Telecommute

Shift

Days

Shift Length

8 Hours

Additional Shift Details

Monday – Friday