Clinical Documentation Specialist HX - Clinical Doc Integrity

CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days

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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. The role proactively solicits clarification from physicians and other healthcare providers when further specificity is needed to ensure accurate quality data and appropriate reimbursement. The Specialist also educates others on documentation guidelines on an ongoing basis and collects and analyzes data to provide reports and make recommendations.

• Facilitate improvement in the overall quality, completeness, and accuracy of medical record documentation through comprehensive audit and evaluation.
• Proactively solicit clarification from physicians and other healthcare providers to ensure accurate quality data and appropriate reimbursement.
• Educate staff on documentation guidelines on an ongoing basis.
• Collect and analyze data to provide reports and make recommendations for improvement.

• Strong clinical knowledge with the ability to interpret clinical documentation.
• Demonstrated customer service skills appropriate to the job.
• Availability for occasional weekend coverage.
• Knowledge of laws, rules, and regulations regarding appropriate clinical documentation, including coding guidelines and coding clinics.
• Five (5) or more years of clinical experience as either an RN or Physician and 3 years’ experience in CDI.
• Familiarity with Utilization Review criteria.
• Familiarity with Joint Commission and CMS requirements.
• Excellent written and verbal communication skills in English.
• Critical thinking skills to problem‑solve and communicate with physicians on clinical issues.
• CDI Credential (CCDS or CDIP).
• Bachelor of Science in Nursing or Medical School Graduate.
• Ability to maintain a work pace appropriate to the workload.
• Ability to influence and work collaboratively with physicians and all levels of staff.
• Ability to establish and maintain effective working relationships across the Health System.

• Previous experience with comprehensive chart/record review.
• Master’s degree with an emphasis in a health‑care related field (nursing, epidemiology, etc.).
• Knowledge of University and medical center organizations, policies, procedures, and forms.
• Experience working within EPIC and 3M 360 Encompass.
• CCS credential.

UCI offers a wealth of benefits including medical insurance, sick and vacation time, retirement savings plans, and a number of discounts and perks. Compensation practices and benefits information can be learned from the internal resources.

All applicants who accept an offer of employment must comply with background check and live scan requirements, employment misconduct disclosure, legal right to work in the United States, vaccination policies, smoking and tobacco policy, drug‑free environment, California Child Abuse and Neglect Reporting Act, E‑Verify, and pre‑placement health evaluation. Additional conditions may apply depending on job‑specific requirements.

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 categories covered by the UC Anti‑Discrimination Policy. UCI is committed to fostering an inclusive, equitable, and welcoming workforce and provides reasonable accommodations for applicants with disabilities upon request.