Clinical Documentation Specialist - Clinical Documentation Integrity (CLIN DOC SPEC 4)

UCSF Medical Center   •  

San Francisco, CA

5 - 7 years

Posted 180 days ago

This job is no longer available.

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. 

Ranked by U.S. News & World Report as the number one hospital in California – and among the top five in the country – 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.

Department Description

Clinical Documentation Integrity (CDI) is a unit of the Department of Quality that reviews provider documentation and facilitates accurate representation of patients treated across UCSF Health. Through collaborative relationships with Faculty practices CDI supports best practices in documentation improvement strategies with an emphasis on severity of illness, medical complexity and quality in the medical record.

CDI closely follows Case mix index, risk adjusted outcomes and Mortality ratings.

Job Summary

The Clinical Documentation Specialist (CDS) facilitates accurate documentation for 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 education of staff in the CDMP® process is a key role.

Required Qualifications

  • Five years current/recent Nursing experience working in ICU, CCU, ED or Med Surg or a combination of education and experience
  • Active CA RN license if Bachelor’s prepared Nurse
  • Bachelor's degree in nursing or related area, and / or equivalent combination of experience / training
  • Successful completion of JA Thomas 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
  • In-depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG 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 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
  • The flexibility to orient and work at all UCSF Medical Center locations

Preferred Qualifications

  • Certification as Clinical Documentation Specialist (CCDS) or Coding certification (ie: CDIP, CCS)
  • One to two years Clinical Documentation Improvement or Quality Improvement experience, preferably at a large Academic Medical Center
  • 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


  • Active CA RN license if Bachelor’s prepared Nurse

Living Pride Standards

Service Excellence

  • Demonstrates service excellence by following the Everyday PRIDE Guide with the UCSF Medical Center standards and expectations for communication and behavior. These standards and expectations convey specific behavior associated with the Medical Center’s values: Professionalism, Respect, Integrity, Diversity and Excellence, and provide guidance on how we communicate with patients, visitors, faculty, staff, and students, virtually everyone, every day and with every encounter. These standards include, but are not limited to: personal appearance, acknowledging and greeting all patients and families, introductions using AIDET, managing up, service recovery, managing delays and expectations, phone standards, electronic communication, team work, cultural sensitivity and competency.   
  • Uses effective communication skills with patients and staff; demonstrates proper telephone techniques and etiquette; acts as an escort to any patient or family member needing directions; shows sensitivity to differences of culture; demonstrates a positive and supportive manner in which patients / families/ colleagues perceive interactions as positive and supportive. Exhibits team work skills to positively acknowledge and recognize other colleagues, and uses personal experiences to model and teach Living PRIDE standards. 
  • Exhibits tact and professionalism in difficult situations according to PRIDE Values and Practices
  • Demonstrates an understanding of and adheres to privacy, confidentiality, and security policies and procedures related to Protected Health Information (PHI) or other sensitive and personal information.
  • Demonstrates an understanding of and adheres to safety and infection control policies and procedures.
  • Assumes accountability for improving quality metrics associated with department/unit and meeting organizational/departmental targets. 

Work Environment

  • Keeps working areas neat, orderly and clutter-free, including the hallways. Adheres to cleaning processes and puts things back where they belong. Removes and reports broken equipment and furniture.
  • Picks up and disposes of any litter found throughout entire facility. 
  • Posts flyers and posters in designated areas only; does not post on walls, doors or windows.
  • Knows where the Environment of Care Manual is kept in department; corrects or reports unsafe conditions to the appropriate departments.  
  • Protects the physical environment and equipment from damage and theft.

The flexibility to orient and work at all UCSF Medical Center locations is required.

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. Further information about the University of California, San Francisco, is available at UCSF seeks candidates whose skills, and personal and professional experience, have prepared them to contribute to our commitment to diversity and excellence, and the communities we serve.

JOb ID: 15426