Registered Nurse Clinical Documentation Integrity

Join to apply for the 2320 Registered Nurse [Clinical Documentation Integrity] role at Contact Investigation.

Department: Public Health

Job class: 2320-Registered Nurse

Salary range: $ - $

Role type: Permanent Civil Service

Hours: Full-time

Exam type: Continuous

Rule: Rule of the List

List type: Entrance

The Department of Public Health prioritizes equitable and inclusive access to quality healthcare for its community and values the importance of diversity in its workforce.

The Mission of the San Francisco Department of Public Health (SFDPH) is to protect and promote the health of all San Franciscans.

• Reviews inpatient medical records for identified payor populations.
• Ensures that clinical documentation reflects the appropriate level of service.
• Utilizes both clinical and coding knowledge effectively.
• Performs initial inpatient chart reviews.
• Manages concurrent medical record reviews.
• Participates regularly in scheduled case management and hospitalist meetings.
• Maintains an up-to-date working DRG and a DRG assignment mismatch report detailing differences.
• Utilizes encoder software to determine the working DRG, performs audits, and communicates daily with HIM coding staff.
• Assists in the development of diagnosis-specific and DRG-specific queries.
• Utilizes documentation improvement communication tools effectively.
• Uses computer-based tools to retrieve and maintain inpatient census data, track coding, and perform audits.
• Resolves inconsistent, conflicting, or ambiguous documentation through the physician query process.
• Follows up with physicians to resolve all queries before the patient's discharge.
• Collaborates with and supports coders.
• Maintains good rapport and cooperative relationships.
• Performs audits to support ongoing monitoring, corrective actions, and improvements within the Clinical Documentation Improvement (CDI) process.
• Collaborates with health information management coding staff, physicians, and financial services. Addresses payment denials, medical necessity issues, and documentation concerns.
• Instructs staff on proper documentation in medical records.
• Reviews inpatient claims with medical necessity denials.
• Maintains detailed Case Mix Index (CMI) reports.
• Fosters respect for privacy by maintaining confidentiality.
• Performs duties in accordance with ethical and legal compliance standards.
• Educates all members of the patient care team on an ongoing basis.
• Actively participates in and supports the Performance Improvement Department.
• Performs other job-related duties as assigned.

LICENSE: Possession of a valid permanent/temporary (including interim permit) California Registered Nurse License (
** IMPORTANT:
** Be sure to include your California RN license number in the application, as failure to do so may result in rejection**)

AND

EXPERIENCE: At least one (1) year of experience working as a Registered Nurse.

• Clinical Documentation Specialist (CCDS) certification
• At least 3 years of clinical experience in an acute care setting
• At least 2 years of experience in clinical documentation integrity/improvement in a healthcare setting

One-year fulltime employment is equivalent to 2,000 hours (2,000 hours of qualifying work experience is based on a 40-hour work week).

Important Note: Please make sure it is absolutely clear in your application exactly how you meet the minimum qualifications.

You will be asked to complete a questionnaire regarding your experience and licensure as part of the application.

Applications for City and County of San Francisco jobs are only accepted through an online process. Visit careers.sf.gov and begin the application process.

The City and County of San Francisco encourages women, minorities and persons with disabilities to apply. Applicants will be considered regardless of their sex, race, age, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, HIV/AIDS status, genetic information, marital status, sexual orientation, gender, gender identity, gender expression, military and veteran status, or other protected category under the law.