Updated: Sep 30, 2022
Location: Orange
Job Type:
Department: Clinical Doc Integrity Program

UC Title: CLIN DOC SPEC 4

Position Number: 40324950

Reports to: Clinical Documentation Mgr 1

Working Title: Clinical Documentation Spec 4

Cost Center: Clinical Doc Integrity Program (428721)

Bargaining Unit: No Bargaining Unit

FLSA: Exempt

Date Created: 8/12/2020

Job Code: 006484

Hours: 40

Shift: Not Applicable

FTE: 1

Position Summary:

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through comprehensive auditing and evaluation of the medical record. Proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. Educates others on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations.

Salary Range:

Annual Rate Minimum $95,300.00 Midpoint $140,400.00 Maximum $185,500.00

Essential Job Functions:

The identification of essential functions below is not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.

Core Organizational Functions:

ACCOUNTABILITY: Responsible for the achievements and success of UC Irvine Health. Follows through and meets commitments; accountable for own actions and supportive of colleagues; presents self in appearance and actions in a manner that conveys professionalism and pride in area of responsibility; projects a positive presence and ensures that work related or personal frustrations are kept separate from patient care and professional activities; takes responsibility for problems and solutions; follows existing policies and procedures.

RESPECT: Foster an environment of mutual respect and trust among ourselves and with all whom we serve. Is always compassionate and empathetic for both patients and team members; makes eye contact, smiles and or greets every individual using the individual’s name, if known; treats all guests and co-workers with the utmost respect, dignity, courtesy and respects their confidentiality; arrives to meetings on time; keeps personal conversations with other employees offstage, out of earshot of patients and visitors.

INTEGRITY: Tells the truth and strives to earn the trust of those around us. Takes pride in their work, being honest and accountable in their words and actions; meets or exceeds department defined service expectations; makes the right decision in the best interest of UC Irvine Health.

INNOVATION: Seeks ideas and approaches that can change the way the world discovers, teaches and heals. Approaches work creatively and continuously looks for new and flexible ways to solve problems; encourages and implements ideas to improve safety, customer service and operational performance; works to create efficient and effective systems so that time is not spent repeating and fixing problems; initiates and supports change.

SERVICE: Collaborates to effectively and compassionately serve our patients, each other and the community. Anticipates customer’s needs; maintains a calm, quiet, healing environment; accepts assignments graciously and carries out duties with pride; recognizes that every individual has an area of expertise and his/her contribution is valuable; keeps patients, families, customers and team members informed about time, thanks the person for waiting, and apologizes for delays.

EXCELLENCE: Committed to achieving the highest level of excellence in patient care, discovery and education. Demonstrates pride; practices humility; embraces greatness; encourages and praises others for work well done; learns to grow developing self and others personally and professionally; is accurate and strives for excellence; creates a positive and productive work climate.

Required Qualifications:

Ability to influence and work collaboratively with physicians and all levels of staff

Familiarity with Utilization Review criteria

Familiarity of Joint Commission and CMS requirements

Ability to establish and maintain effective working relationships across the Health System

Ability to maintain a work pace appropriate to the workload

Must demonstrate customer service skills appropriate to the job

Excellent written and verbal communication skills in English

Critical thinking skills to problem solve and communicate with physicians on clinical issues

CDI Credential (CCDS, CDIP)

Knowledge of laws, rules and regulations regarding appropriate clinical documentation including coding guidelines and coding clinics

Bachelor of Science in Nursing or Medical School Graduate

Five (5) or more years of clinical experience as either an RN or Physician and 3 years’ experience in CDI

Must possess the skill, knowledge and ability essential to the successful performance of assigned duties

Must be available for occasional weekend coverage

Strong clinical knowledge with ability to interpret clinical documentation

Preferred Qualifications:

Previous experience with comprehensive chart / record review

Master’s degree with an emphasis in health care related fields (nursing, epidemiology, etc.)

Experience working within EPIC and 3M 360 Encompass CAC

Knowledge of University and medical center organizations, policies, procedures and forms

CCS credential

Conditions of Employment:

The University of California, Irvine (UCI) seeks to provide a safe and healthy environment for the entire UCI community. As part of this commitment, all applicants who accept an offer of employment must comply with the following conditions of employment:

• Background Check and Live Scan
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment

The following additional conditions may apply, some of which are dependent upon business unit or job specific requirements.

• California Child Abuse and Neglect Reporting Act

• E-Verify
• Pre-Placement Health Evaluation

Details of each policy may be reviewed by visiting the following page: https://hr.uci.edu/new-hire/conditions-of-employment.php

Closing Statement:

The University of California, Irvine is an Equal Opportunity/Affirmative Action Employer advancing inclusive excellence. 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 categories covered by the UC nondiscrimination policy.

We are committed to attracting and retaining a diverse workforce along with honoring unique experiences, perspectives, and identities. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable and welcoming.

UCI provides reasonable accommodations for applicants with disabilities upon request. For more information, please contact UCI’s Employee Experience Center (EEC) at eec@uci.edu or at (949) 824-0500, Monday – Friday from 8:30 a.m. – 5:00 p.m.