Clinical Documentation Specialist

  • UCLA Health
  • Los Angeles, CA, USA
  • Jun 30, 2020

Job Description


As the Clinical Documentation Specialist, you will be responsible for:

·       Completing review of medical record for identified patients in the required timeframes

·       Identify and creates documentation queries to be sent to physicians, residents and mid-levels.

·       Communicate with physicians face to face or via CDI query forms to clarify information, obtain needed documentation and educate for appropriate DRG based on severity of illness and risk of mortality

·       Follow up on all queries sent and maintains timely review of medical records while patient remains an inpatient

·       Applies appropriate documentation to a computer database (Care Connect and CDR2) to identify the most appropriate diagnosis and CC’s to accurately reflect the severity of illness

·       Continuously confers with hospital coding staff to ensure appropriate DRG and completeness of supporting documentation

·       Assess and improve physician, case manager, nurse and other education for the health team to promote complete and accurate clinical documentation and correct negative trends

·       Conduct seminars and presentations to hospital staff, as needed, to educate on specific departmental and hospital-wide topics related to clinical documentation and quality


We’re seeking a detail-oriented, self-directed professional with:

·       California Registered Nurse (or equivalent) license

·       Minimum of three years of clinical hospital experience; or equivalent of education and experience in case management, utilization management or prior clinical documentation review experience

·       Recent experience in care management, quality utilization or coding

·       Working knowledge of laws, rules and regulations regarding appropriate clinical documentation for government programs as Medicare and MediCal

·       Leadership, supervisory, and training skills

·       Working knowledge of a large University teaching hospital; its purpose and functions

·       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

·       Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel

UCLA 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, disability, or protected Veteran status.




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