CLIN DOC SPEC 3 HX

Job Description

Job Function Summary:

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. Interacts with physicians, clinical staff, and health information management professionals. 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.

Generic Scope (not customizable, will not be used in the job posting/advertisement):

Experienced professional who knows how to apply theory and put it into practice with in-depth understanding of the professional field; independently performs the full range of responsibilities within the function; possesses broad job knowledge; analyzes problems / issues of diverse scope and determines solutions.

Custom Scope (customizable, will be used in the job posting/advertisement):

Applies skills and experience as a seasoned clinical documentation specialist to projects of medium size at all levels of complexity, or portions of large projects.

Qualifications

Knowledge, Skills and Abilities Req / Pref 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. Req 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. Req Thorough knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement. Req Detail oriented, with proven organizational skills and the ability to effectively manage time, prioritize tasks, and see complex projects through to completion on schedule. Req 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. Req 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. Req Proven ability to interpret and effectively convey complex clinical and technical information both verbally and in writing, and to make cogent presentations, analyses, and reports. Req 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. Req Proven computer proficiency in relevant multiple technology applications. Req 3 years related work experience Req Education Req / Pref Bachelor's degree in PT/OT/SPT Required

License / Certification

Licensed Occupational Therapis, Physical Therapist, Speech Language Pathologist

About UCSF

The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world's leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells.

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 https://www.ucsf.edu/about/mission-and-values . In addition to , 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 https://diversity.ucsf.edu/ . Join us to find a rewarding career contributing to improving healthcare worldwide.

EEO Statement

The University of California is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age, protected veteran status, or other protected status under state or federal law.