Skip to content

General Information

Job Name
Clinical Documentation Specialist within PT/OT/SPT
Department
6440030 - Physical Rehabilitation Care Hyde Hospital
Position type
Part Time
Workplace
Fully On-Site
Primary Location
San Francisco, CA, United States
Job ID
CONV_87811BR

Description & Requirements

Job Description
Involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient’s severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any coexisting co-morbidities are a complete reflection of the patient’s clinical status and care. Involves education and training to physicians and clinical staff (nurses and therapists) as part of the onboarding and as rules and regulations change in the IRF level of care. The final salary and offer components are subject to additional approvals based on UC policy.
Qualifications
Required Qualifications : - Bachelor's degree in PT, OT or Master in SLP or related area, and / or equivalent combination of experience / training California License on respective fields (PT, OT, SLP or RN) - Min 2 years Clinical experience post-grad in a hospital setting. - Working knowledge and experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, case management, discharge, and other practices that are part of effective clinical care systems. - Detail oriented, with demonstrated ability to effectively manage time, see tasks through to completion, organize competing priorities, and effectively address complex, urgent issues as they arise. - Demonstrated critical-thinking and problem-solving skills to manage multiple levels of information and responsibilities, and quickly assess problems to develop multiple potential solutions. - Demonstrated interpersonal and educational skills, with the ability to collaborate effectively with clinical-care professionals, and to serve as an educational resource on coding, reimbursement, and other clinical documentation issues. - Demonstrated ability to interpret and effectively explain clinical and technical information both verbally and in writing, and to contribute to presentations, reports, and analyses as assigned. - Demonstrated ability to work with senior staff and managers and to provide recommendations on issues of functionality, clinical quality, and efficiency. - Demonstrated computer proficiency in relevant multiple technology applications. - Has flexibility to work across the system Preferred Qualifications : - Working knowledge of the concepts, principles, practices, and regulatory requirements of accurate clinical documentation and medical record review, including SOI, ROM, HIMS, ICD-10 coding, DRG systems, standards of compliance, relevant Medicare Part A and Part B guidelines and other reimbursement processes. - Working knowledge of data collection, analysis, reporting techniques and systems, and of health care information management systems related to clinical care, documentation, reporting, and reimbursement. - PT
About UCSF
The University of California, San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It is the only campus in the 10-campus UC system dedicated exclusively to the health sciences. We bring together the world’s leading experts in nearly every area of health. We are home to five Nobel laureates who have advanced the understanding of cancer, neurodegenerative diseases, aging and stem cells.
Pride Values
UCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence – also known as https://www.ucsf.edu/about/mission-and-values . In addition to , UCSF is committed to equity – both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available https://diversity.ucsf.edu/ . Join us to find a rewarding career contributing to improving healthcare worldwide.
EEO Statement
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 other protected status under state or federal law.

Additional Details

Job Code
CLIN DOC SPEC 2 HX (004970)
Assignment Category
Career
IAP Level
Staff Plan (target potential payout of $900, maximum of $1,800)
Job Family
Quality Management
Campus 1
St. Francis
Campus 2
St. Francis
Campus 3
St. Francis
Percentage (%)
60
Shift Length
8 hours
Shift Type
Day
Bargaining Unit
HX
Additional Shift Details
Monday - Friday, Variable
Go back

Similar jobs

View all