The Clinical Documentation Specialist 4 is chiefly responsible for ensuring the physician's clinical documentation appropriately captures resource intensity and severity of illness. The incumbent is responsible for concurrent review and analysis of the clinical documentation in the medical records using query of the Medical Staff and other caregivers as necessary with documentation query forms or verbal communication. This position ensures accurate and complete clinical documentation is obtained that appropriately supports the severity of patient illness and the intensity of the services ordered. The Clinical Documentation Specialist 4 also assists in the education of medical staff and other caregivers relating to clarity and completeness of the clinical documentation.REQUIRED - RN or Physician (or other Doctorate) with minimum of 3 years of acute care experience. - Advanced experience reading/abstracting handwritten and transcribed documents in the medical record and interpreting the clinical information.- Comprehensive knowledge of medical diagnostic and procedural terminology.- College level understanding of disease processes, anatomy, and physiology. - Knowledge of and understanding of multi-medical specialties and procedures in acute and critical care setting.- Broad-based clinical experience with a demonstrated experience in patient care delivery in critical and acute care setting.- Written and verbal communication skills to clearly and concisely compose letters, reports, policies and procedures.- Must be able to read and comprehend English text and medical terminology.- Knowledge of medical and nursing treatment plans and levels of care associated with acute and critical care.- Skill to perform in-depth chart analysis.PREFERRED - RHIA, RHIT, CCS, CDIP, or CCDS. - Experience in an academic/healthcare setting.SPECIAL REQUIREMENTS - THIS POSITION MAY BE SUBJECT TO A CRIMINAL BACKGROUND INVESTIGATION, DRUG SCREEN, LIVE SCAN FINGERPRINTING, MEDICAL EVALUATION CLEARANCE, AND FUNCTIONAL CAPACITY ASSESSMENT.- Must be able to work occasional overtime and flexible hours. - Must be able to lift 25 pounds and walk, sit, or stand for prolonged periods of time.
Internal Number: 052855
About University of California Davis Medical Center
At the end of 2015, we launched a comprehensive and inclusive process to tap into the broad, diverse knowledge of our entire UC Davis Health community to stimulate new and unique ideas for our next strategic plan.Throughout 2016, hundreds of members of our UC Davis Health family, as well as external friends and partners, took part in conversations and provided valuable input into charting a long-term course for our future that will continue the momentum underway to solidify our position as a top-tier health care organization.With your valuable input and talents, I am excited to launch our six new strategic plan goals. Over the next few years, together we will:Lead Person-Centered Care in the best way, at the best time, in the best place, and with the best teamReimagine Education by cultivating diverse, transdisciplinary, life-long learners who will lead transformation in health care to advance well-being and equity for allAccelerate Innovative Research to improve lives and reduce the burden of disease through the discovery, implementation and dissemination of new knowledgeImprove Population Health through the use of big data and precision healthTransform Our Culture by engaging eve...ryone with compassion and inclusion, by inspiring innovative ideas, and by empowering each otherPromote Sustainability through shared goals, balanced priorities and investments in our workforce and in our communityAt a time when our industry is experiencing some of the most formidable changes ever, these are bold aspirations that will anchor us and provide us with clarity of purpose and a path forward. I am fully confident that we will achieve great success knowing we have a solid plan and areas of focus to guide us.I thank everyone who participated in the planning process for their great input and their dedication to our future success.