Clinical Documentation Specialist

19 hours ago


San Diego, California, United States UC San Diego Health System - Hillcrest Full time
Job Title: Clinical Documentation Specialist

We are seeking a skilled Clinical Documentation Specialist to join our team at UC San Diego Health System - Hillcrest. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of patient medical documentation.

Responsibilities:
  • Perform complex reviews of patient medical documentation to evaluate quality measures, consistency, and completeness of documents.
  • Evaluate the accuracy of patient medical documentation for severity of illness (SOI) and risk of mortality (ROM).
  • Establish productive working relationships with clinicians, patient care staff, and health information management (HIM) personnel.
  • Communicate effectively with all levels of physicians, advanced practice providers, and staff onsite.
  • Proficiently use EPIC and CDS software, including Computer Assisted Coding systems such as 3M 360 and Optum.
Requirements:
  • Required: BSN or FMSG degree.
  • Preferred: CCDS or CDIP certification.
Work Environment:

This position is located at the La Jolla Campus, but the successful candidate must be able to travel to La Jolla/Hillcrest/East Campus as needed.

We offer a dynamic and supportive work environment, with opportunities for professional growth and development. If you are a motivated and detail-oriented individual with a passion for healthcare, we encourage you to apply for this exciting opportunity.



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