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UCSF Health

Clinical Document Specialist

UCSF Health, San Francisco, California, United States, 94199

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Clinical Document Specialist

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UCSF Health

Job Summary Involve evaluating provider documentation, using clinical expertise to ensure patients’ severity of illness and risk of mortality are accurately portrayed in the medical record.

Work with physicians, clinical staff, and health information management and coding staff to ensure that documentation of all diagnoses and any co‑existing comorbidities reflects the patient’s clinical status and care.

Clinical Documentation Program

Employment type: Full time

Job Code: 87206BR

Career level: Career

✓ Work Style: Fully Remote

Location: San Francisco, CA (Hyde Campus)

Shift: Days – 8 hours (Mon – Fri)

Salary range: $121,900 – $277,100 (Annual Rate).

Final salary and other offer components are subject to further approval based on UC policy.

Placement is guided by work experience, internal equity, and collective bargaining rules when applicable.

For more information on benefits and total compensation, visit https://ucnet.universityofcalifornia.edu/compensation-and-benefits/index.html

Required Qualifications

Advanced knowledge and experience with inpatient care clinical and operational issues, including diagnoses, treatments, procedures, case management, discharge, and related practices.

Advanced critical thinking and problem‑solving skills for managing multiple levels of information and quickly assessing complex problems.

Advanced interpersonal and educational skills, able to collaborate on complex projects with clinical‑care professionals and provide training on coding, reimbursement, and documentation.

Advanced ability to interpret and convey complex clinical and technical information verbally and in writing, making clear presentations, analyses, and reports.

In‑depth ability to collaborate with senior staff across departments, offering guidance on improving clinical quality, efficiency, and proficiency in technology applications.

Advanced computer proficiency in multiple technology applications.

5+ years of related work experience.

Bachelor’s degree in nursing or related area, and/or equivalent combination of experience and training.

Five years of current/recent clinical experience working in ICU, CCU, ED or Med‑Surg (or a combination of training and experience).

Successful completion of Nuance pre‑hire exam.

Flexibility to orient and work at all UCSF Medical Center locations.

Preferred Qualifications

Advanced knowledge of data collection, analysis, reporting techniques and systems related to clinical care and reimbursement.

In‑depth understanding of accurate documentation principles, SOI, ROM, HIMS, ICD‑10 coding, DRG systems, compliance standards, Medicare Part A and B guidelines, and reimbursement processes.

Advanced organizational and project‑management skills, able to lead a team and prioritize tasks, delivering projects on schedule.

California nursing license.

Certification as a Clinical Documentation Specialist (CCDS).

About UCSF UCSF Health’s mission of innovative patient care, advanced technology, and pioneering research is redefining what’s possible for the patients we serve.

Consistently ranked among the top 10 hospitals nationally, UCSF Health offers opportunities for continuous learning and professional growth.

Pride Values UCSF is a diverse community.

We seek candidates whose experience or community service prepares them to contribute to our commitment to professionalism, respect, integrity, diversity, and excellence – our PRIDE values.

We also are committed to equity in care delivery and our workforce.

Equal Employment Opportunity 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 any other protected status under state or federal law.

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