Clinical Documentation Integrity Specialist

Make a positive impact on one of the nation’s top health systems. Help ensure the efficient delivery of award-winning patient care. Take your professional expertise to the next level. UCan do all this and more at UCLA Health.

You will become a member of our highly successful Documentation Improvement Integrity team, including all modalities. This will involve daily reviews of high acuity patient records; continuously communicating with department staff; educating physicians, residents and mid-levels; and assisting with appropriate documentation strategies. Partnering with Medical Coding, Case Management and the Quality team, you will gather/analyze information to provide comprehensive medical record documentation that accurately reflects clinical treatment, decisions, and diagnoses. You will utilize your clinical expertise and coding knowledge to identify opportunities and ensure accuracy and completeness of clinical documentation. You will also leverage physician queries to improve documentation quality while providing key support to medical coders, case managers and Quality staff.

Salary Range: $92,600.00 - $202,200.00/year

We’re seeking a detail-oriented, collaborative, self-directed individual with:

1. Bachelor’s degree in health-related field, preferred
2. A Registered Nurse (RN) license or MD diploma (or equivalent) required
3. Five or more years of clinical hospital experience; or equivalent of education and experience in case management, utilization management or prior clinical documentation review experience, required
4. Knowledge of coding guidelines and coding clinic, required
5. Knowledge of laws, rules and regulations regarding appropriate clinical documentation for Medicare, Medi-Cal, CCS etc.
6. Strong leadership, supervisory, and training skills
7. Excellent critical thinking abilities
8. Experience working within EPIC and 3M 360 Encompass CAC, required
9. Resourcefulness and strong communication, organizational, and analytical skills
10. Ability to work effectively with physician/staff and interdisciplinary teams
11. Computer proficiency and proficiency in Word, Excel and PowerPoint, required
12. Skill in abstracting/interpreting medical information from patient records, required
13. Clinical experience sufficient to understand and communicate medical diagnoses and courses of treatment to professional and non-professional personnel, required
14. Knowledge of computer word processing, database programs, and ability to write reports and do graphical analysis, required

Note: Skills may be subject to test.