Clinical Documentation | UCSF Human Resources

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 co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

Title	Exempt / Non-exempt	Personnel Program	Grade
Clinical Documentation Specialist 2 Job code: 4178 Level code: P2	NE	PSS	22
Clinical Documentation Specialist 3 Job code: 4177 Level code: P3	E	PSS	24
Clinical Documentation Specialist 4 Job code: 6484 Level code: P4	E	MSP	25
Clinical Documentation Supv 2 Job code: 6483 Level code: S2	E	MSP	25
Clinical Documentation Manager 1 Job code: 6482 Level code: M1	E	MSP	26
Clinical Documentation Manager 2 Job code: 6791 Level code: M2	E	MSP	27