Clinical Documentation Specialist
 University of California- Davis Health | |
$9,283.33
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vision insurance, parental leave, paid time off, paid holidays, sick time, long term disability, tuition reimbursement
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 United States, California, Sacramento | |
 Feb 20, 2026 | |
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Apply for Job Job ID
84445
Location
Sacramento
Full/Part Time
Full Time
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#CA-KN This position is chiefly responsible for ensuring the physician's clinical documentation appropriately captures resource intensity and severity of illness. Responsible for concurrent review and analysis of the clinical documentation in the medical records using query of the Medical Staff and other care givers as necessary with documentation query forms or verbal communication to obtain accurate and complete clinical documentation that appropriately supports the severity of patient illness and the intensity of the services ordered. Also assists in education of Medical Staff and other care givers relating to clarity and completeness of the clinical documentation. Apply By Date: 3/1/2026 at 11:59 pm - Interviews and recruiting process may occur at any time Minimum Qualifications - For full consideration, applicants are encouraged to upload license and/or certification if required of the position
Preferred Qualifications
Key Responsibilities
Department Overview The Health Information Management Department is comprised of multiple units with a staffing of more than 300 FTEs, whose primary purpose is to serve the interests of the individual patient by facilitating medical care, treatment, research, and teaching through the availability of a well-documented, current medical record and clinical database. Department Specific Job Scope Clinical Documentation Specialist - Intensity of Service and Severity of Illness. Conducts initial concurrent review and subsequent reviews for all selected admissions to initiate the clinical document review process and then document findings on DRG worksheets. Also identifies other key pathway or quality indicators, as appropriate. Concurrent review and analysis of the clinical documentation in the medical records to identify the need to query the Medical Staff and other care givers as necessary with documentation query forms/verbal communication to obtain accurate and complete documentation that appropriately supports the severity of illness, and the intensity of the services ordered. Identifies and records principal, secondary, and co-morbid diagnoses, and principal procedures for assignment of a working DRG. Collaborates with physicians, nurses, UR Case Managers and medical record inpatient coders as needed. Identifies need to clarify documentation in the medical record and initiates communication with physicians by using the "Documentation Request" tools to capture the documentation in the medical records that supports patient's SI/IS. Provides information and education to physicians and ancillary staff not responding to prompters. Provides education to the Medical Staff and other care givers relating to clarity and completeness of clinical documentation. Conducts ongoing physician and staff education in medical staff meetings or on an individual basis as necessary. Ensure that all diagnoses and procedures that may impact the facility's reimbursement or reported quality measures are identified and documented correctly. Ensures that critical lab values have working diagnosis in medical record to support severity of illness. Ensures that intensity of resources utilized corresponds to a working clinical diagnosis, complication, condition or disease process. Responsible and reviews medical record to ensure historical diagnosis and co-morbid conditions are documented in the medical record. Works with inpatient coding staff to assign Diagnoses-Related Groups (DRGs) to all inpatient records after identifying the principal diagnosis (reason for admission) and significant complications and/or co-morbidities as well as operating room procedures and diagnostic procedures following comparison of relative weights in the DRG GROUPER software, and selection of the highest reimbursement allowable among alternative principal diagnoses documented in the record, while adhering to coding guidelines, CMS, and AHIMA code of ethics. Consults with physicians for clarifications of clinical data when encountering conflicting or ambiguous information and/or significant missing documentation. Achieves a balance in quality and quantity, with a goal of maintaining both elements at a prescribed level of efficiency. Identifies and prioritizes cases for review, per department guidelines. May assist with utilizing monitoring tools to track the progress of the DRG Assurance Program, may interpret tracking information and report findings to coworkers at regular DRG Assurance Program meetings and facilitates communication with Medical Record coders. May assist in the development and distribution of APR/DRG physician profiling reports. Identifies quality variances that can be abstracted concurrently.10% Educational Experiences related to coding challenges. Participates in Coding Team's regular meetings with the objective of solving problems, brainstorming, educating physicians and others as to the coding policies and procedures of the facility, as well as promoting consistent interpretation of clinical documentation. Maintains knowledge of current information related to DRG methodology including diseases, procedures, conditions, and complications that impact the DRG assignment. Maintains a working knowledge of regulatory changes affecting coded information required by the Center for Medicare and Medicaid Services, and other as appropriate. Maintains licensure/certification. Assists in establishing and maintaining policies and procedures for CDS Unit. Performs additional duties as assigned by the supervisor and/or management, in accordance with established guidelines and deadlines. POSITION INFORMATION
Benefits Outstanding benefits and perks are among the many rewards of working for the University of California. UC Davis offers a full range of benefits, resources and programs to help you bring your best self to work, as well as to help you and your family achieve your health, wellness, financial and career goals. Learn more about the benefits below and eligibility rules by visiting either our handy Benefits Summary for UC Davis Health Employees or Benefits Summary for UC Davis Employees and our Benefits Page.
Physical Demands
Mental Demands
Work Environment UC Davis is a smoke and tobacco free campus effective January 1, 2014. Smoking, the use of smokeless tobacco products, and the use of unregulated nicotine products (e-cigarettes) will be strictly prohibited on any UC Davis owned or leased property, indoors and outdoors, including parking lots and residential space. Special Requirements - Please contact your recruiter with questions regarding which activities apply by position
Misconduct Disclosure Requirement: As a condition of employment, the final candidate who accepts a conditional offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; received notice of any allegations or are currently the subject of any administrative or disciplinary proceedings involving misconduct; have left a position after receiving notice of allegations or while under investigation in an administrative or disciplinary proceeding involving misconduct; or have filed an appeal of a finding of misconduct with a previous employer. A Culture of Opportunity and Belonging At UC Davis, we're committed to solving life's most urgent challenges and building a healthier, more resilient world. We believe in growing through every challenge, continually striving to improve, and welcoming new perspectives that strengthen our community. We recognize that a vibrant and innovative organization values both individual strengths and shared purpose. The best ideas often emerge when people with different experiences come together. | |