Documentation Specialist Jobs in California

UCI Health is one of California's largest academic health systems and the clinical enterprise of the University of California, Irvine. Established on July 1, 1976, UCI Health has grown into a 1,461-bed health system that includes UCI Health - Orange, UCI Health - Irvine, four Community Network hospitals and a growing network of ambulatory care centers across Orange and Los Angeles counties.

As Orange County’s only academic health systems, UCI Health is home to the only National Cancer Institute-designated comprehensive cancer center based in the county, the region’s only American College of Surgeons-verified Level I adult and Level II pediatric trauma center, American College of Emergency Physicians Gold Level 1 Geriatric Emergency Department and a nationally recognized regional burn center verified by the American Burn Association. Powered by UC Irvine, UCI Health serves 5.6 million people across Orange County, western Riverside County and southeast Los Angeles County through excellence in patient care, research and medical education.

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.

• Strong clinical knowledge with ability to interpret clinical documentation

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

• Must demonstrate customer service skills appropriate to the job

• Must be available 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 of 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 health care related fields (nursing, epidemiology, etc.)

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

• Experience working within EPIC and 3M 360 Encompass CAC

• CCS credential

We offer a wealth of benefits to make working at UCI even more rewarding. These benefits may include medical insurance, sick and vacation time, retirement savings plans, and access to a number of discounts and perks. Please utilize the links listed here to learn more about our compensation practices and benefits.

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
• Employment Misconduct*
• Legal Right to Work in the United States
• Vaccination Policies
• Smoking and Tobacco Policy
• Drug Free Environment

• Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer.

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

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.

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.