August 12, 2016
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Clinical Documentation Specialist

University of California - Los Angeles Medical Centers - Los Angeles, CA

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Job Description

Job Title:
Clinical Documentation Specialist

UCLA Title:
Clin Spec Ex

Job No.:

Work Hours:

Work Location:

Job Type:


Minimum Salary:
$19.19 / $3338

Maximum Salary:
$69.07 / $12018

Layoff Referral Deadline:

Bargaining Unit:


Completes review of medical record for identified patients in the required timeframe.
Communicates with physicians face to face or via clinical documentation inquiry forms
to clarify information, obtain needed documentation and educate for appropriate clinical documentation that will accurately reflect patient severity of illness and risk of mortality. Follows up with appropriate health team members to ensure accurate and complete documentation in the medical record. Demonstrates an understanding of complications, HACs, PSI, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, and impact of procedures on DRG; and is able to share this knowledge to physicians and other health team member. Confers with physicians, nursing, case management and other clinical caregivers to explain the importance of clear and concise documentation. Confers with hospital coding staff to ensure appropriate DRG and completeness of supporting documentation. Collaborates with coders to ensure AR days remain in target range. Reviews records upon coding request to confirm DRG assignment or need to follow up with physician regarding incomplete documentation. Maintains accurate data in the tracking database. Provides reports and identifies trends as needed. Provides required/requested information, inappropriate resource utilization, statistical data or reports for Hospital Administration, Hospital Utilization Committee or Medical Coding. Achieves and maintains current knowledge and understanding of ICD-9 coding and DRG systems, through participation in education and training, including reading and comprehension of AHIMA Coding Clinic & coding guidelines. Develops and maintains knowledge and understanding of ICD-10, demonstrating work appropriate competency.


Ability to effectively communicate to physician/staff the necessity/appropriateness of clinical documentation
Ability to effectively communicate to the payer the medical necessity/appropriateness /level of care criteria that is necessary for acute care hospitalization.
Skills in setting priorities that accurately reflect the relative importance of job responsibilities.
Skill in abstracting and interpreting medical information from patient records.
Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS.
Strong clinical knowledge t to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel.
Immediate knowledge of computer word processing, database programs and ability to write reports and do graphical analysis.

License: RN, Coding Specialist, preferred Degree: BS in health related field, preferred

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