September 22, 2016
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Clinical Documentation Specialist - Clinical Documentation Integrity (CLIN DOCUMENTATION SPEC 3)

University of California - San Francisco Medical Centers - San Francisco, CA

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Job Description

Job Title

Clinical Documentation Specialist - Clinical Documentation Integrity (CLIN DOCUMENTATION SPEC 3)

Job ID


Job Code


Job Family

Professional Support Staff



Weekly Hours

40 ; 100%

Appointment Type



Clin Documentation Mgmt Prgm


8-hour Days

Full/Part Time


Union Information

This classification is not represented by a union

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Our legacy of unsurpassed patient care and unceasing mission to integrate high-tech medical research with clinical operations has led to our prestigious standing as one of the top 10 hospitals in the nation according to U.S. News & World Report. As a premier health care institution dedicated to advancing health worldwide, UCSF Medical Center can also be the best place to advance and shape your career.

The medical center's employees are one of the most important reasons why we are recognized as one of the nation's best hospitals. To work at UCSF Medical Center is to be part of an institution that provides the highest caliber of care to patients; a nurturing, dynamic and team-oriented atmosphere in which to best use your skills and talents.

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.

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

Required Qualifications

* Active CA RN License (if nursing prepared)

* Bachelor s degree in nursing or related medical area; and/or equivalent combination of experience / training

* Achieve passing score of 75% or higher on JA Thomas pre-test

* Thorough knowledge and 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

* Thorough 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

* Thorough 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

* Detail oriented, with proven organizational skills and the ability to effectively manage time, prioritize tasks, and see complex projects through to completion on deadline

* Strong critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess complex problems to develop multiple potential solutions

* Strong interpersonal and educational skills, with the ability to ability to collaborate effectively with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues

* Proven 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

* Strong ability to work with senior staff and managers across departments and to provide advice and recommendations on 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

* Five years current/recent Nursing experience working in ICU, CCU, ED or Med Surg or a combination of education and experience

* 1-2 years Clinical Documentation Improvement experience, preferably at a large Academic Medical Center

* CCDS certification and/or Coding certification (ie: CDIP, CCS)

* Ability to exhibit and perform analytic processing skills


* Active CA RN License

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.

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.


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