You can make a difference in people's lives every day. When you join UCLA Health, you'll be working at an institution that provides leading-edge care to the people of L.A. and throughout the world. We provide our team members with the environment and support to do amazing work, because each and every one of them plays a vital role in our commitment to care.
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
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.
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
Posting ID: 559537261Posted: 2020-06-04