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Involves the evaluation and analysis of provider documentation, utilizing clinical expertise to ensure that patient's severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and accuracy in all quality outcomes. Interacts with physicians, clinical staff, and health information management coding staff to ensure that documentation of all diagnoses and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.
% of time |
Essential Function (Yes/No) |
Key Responsibilities (To be completed by Supervisor) |
50 |
Yes |
Conducts timely concurrent case reviews of clinical documentation in highly complex cases, evaluating quality, consistency, completeness and accuracy for severity of illness (SOI) and risk of mortality (ROM). Requires high level critical thinking and analytical skills related to conditions treated and evaluated at academic medical centers. Requires precision and diligence for sustained efforts with attention to detail. Requires self reliance and ability to research clinical concepts. Manages high volume case assignments, re-reviews and discharges. Highly specialized learning environment requires adaptability, flexibility, self-awareness and the ability to accept and apply constructive guidance. |
20 |
Yes |
Establishes collaborative working relationships with clinicians, patient care professionals, health information management (HIM), and coding staff, as well as managers in clinical, quality, and information technology. Works on highly complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment. |
10 |
Yes |
Works closely with HIM coding staff to ensure that all clinical documentation is fully compliant and accurately reflects the patient's condition, treatments, and co-morbidities. Conducts reviews on specific cases involving mortalities, multiple complications for final outcomes with coding team. |
10 |
Yes |
Analyzes highly complex data to identify trends, errors, inconsistencies, variances, or flags that may require an update to the documentation or coding. Recommends timely and effective strategies for revising codes or correcting clinical documentation to resolve problems and improve compliance. |
10 |
Yes |
Maintains current knowledge of best practices related to coding, diagnoses, treatment, and reimbursement. Serves as an expert resource to all levels of clinical staff and participates in the development of education shared with clinical teams and professional staff to achieve improved results in clinical documentation. |
100% |
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REQUIRED QUALIFICATIONS
Five years of current/recent clinical experience working in ICU, CCU, ED or Med Surg or a combination of education and experience Bachelor's degree in nursing or related area, and / or equivalent combination of experience / training. - Successful completion of Nuance pre-hire exam
Advanced knowledge and experience with the clinical and operational issues involved with inpatient care, including 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 highly complex projects with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues. Advanced ability to interpret and effectively convey highly complex clinical and technical information both verbally and in writing, 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 proficiency in relevant multiple technology applications. Advanced computer proficiency in relevant multiple technology applications. This position requires flexibility to orient for all patient populations across UCSF Health.
PREFERRED QUALIFICATION
In depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIM, ICD-10 coding, DRG system, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes. Advanced knowledge of data collection, analysis, reporting techniques and systems, and of health care information 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. CA Nursing license Certification as Clinical Documentation Specialist (CCDS)
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 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 here.
Join us to find a rewarding career contributing to improving healthcare worldwide.
Equal Employment Opportunity
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.
Salary Information
The final salary and offer components are subject to additional approvals based on UC policy.
Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement.
To learn more about the benefits of working at UCSF, including total compensation, please visit: https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html REQUIRED QUALIFICATIONS
Five years of current/recent clinical experience working in ICU, CCU, ED or Med Surg or a combination of education and experience Bachelor's degree in nursing or related area, and / or equivalent combination of experience / training. - Successful completion of Nuance pre-hire exam
Advanced knowledge and experience with the clinical and operational issues involved with inpatient care, including 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 highly complex projects with clinical-care professionals, and to provide education, training, and resources on coding, reimbursement, and other clinical documentation issues. Advanced ability to interpret and effectively convey highly complex clinical and technical information both verbally and in writing, 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 proficiency in relevant multiple technology applications. Advanced computer proficiency in relevant multiple technology applications. This position requires flexibility to orient for all patient populations across UCSF Health.
PREFERRED QUALIFICATION
In depth understanding of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIM, ICD-10 coding, DRG system, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes. Advanced knowledge of data collection, analysis, reporting techniques and systems, and of health care information 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. CA Nursing license Certification as Clinical Documentation Specialist (CCDS)
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University of California - San Francisco
188,000 to 200,000
May 19, 2026