Clinical Documentation Specialist

Clinical Documentation Specialist PHYSICAL REHABILITATION CARE Part Time 87811BR Job Summary 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. Your placement within the salary range is dependent on a number of factors including your work experience and internal equity within this position classification at UCSF. For positions that are represented by a labor union, placement within the salary range will be guided by the rules in the collective bargaining agreement. The salary range for this position is $38.94 - $85.52 (Hourly Rate). To learn more about the benefits of working at UCSF, including total compensation, please visit: Required Qualifications 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 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) 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. License/Certification California License on respective fields (PT, OT, SLP or RN) About UCSF At UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team. Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents. 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 our PRIDE values. In addition to our PRIDE values, 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 at diversity.ucsf.edu Join us to find a rewarding career contributing to improving healthcare worldwide. 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 other protected status under state or federal law. Organization Health Job Code and Payroll Title 004970 CLIN DOC SPEC 2 HX Job Category Allied Health Bargaining Unit University Professional and Technical Employees - Health Care Professionals Unit (UPTE-HX) Employee Class Career Percentage 60% Location San Francisco, CA Campus Hyde (SF) Work Style Fully On-Site Shift Days Shift Length 8 Hours Additional Shift Details Monday - Friday, Variable

Created: 2026-03-05