Clinical Documentation Specialist at University of California - Los Angeles Medical Centers in Los Angeles, California

Job Description:

Responsibilities

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
Qualifications

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.