CDI Specialist: Elevate Clinical Documentation

Memorial Physician Practices; Clyde (NC); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Comprehensive Benefits

401(k) retirement plan with match

Tuition assistance for education

Job summary

Haywood Regional Medical Center is seeking a Clinical Documentation Specialist to review patient records for accuracy, completeness and compliance. You will collaborate with providers to clarify diagnoses and procedures according to coding guidelines and organizational policies.

The role supports quality improvement and ongoing education while upholding HIPAA and safety standards. Join a team dedicated to improving community health in Western North Carolina.

Qualifications

• Minimum of 1 year of healthcare-related experience
• Knowledge of medical terminology, coding practices, and clinical workflows preferred
• RHIT/RHIA/CCS-P/CCS or RN/LPN credentials are preferred in the state of practice

Responsibilities

• Facilitate improvement in clinical documentation quality, completeness and accuracy by collaborating with physicians, coders and other team members
• Conduct daily reviews of inpatient records to identify missing or unclear diagnoses and procedures and perform timely follow-up
• Identify documentation improvement opportunities and support accurate reporting of outcomes per guidelines and regulations
• Develop compliant physician queries based on clinical indicators and coding guidelines
• Serve as a documentation resource for physicians and staff with education and guidance on documentation requirements
• Conduct educational sessions for physicians, clinical staff, coding teams and stakeholders to promote compliant documentation
• Track CDI performance using metrics and reports and support process improvement
• Prepare reports related to CDI performance and regulatory compliance while maintaining confidentiality

Skills

Healthcare documentation

Communication

Analytical thinking

Attention to detail

Education

RHIT

RHIA

CCS-P

CCS

RN

LPN

Job description

Haywood Regional Medical Center is seeking a Clinical Documentation Specialist to review patient records for accuracy, completeness and compliance. You will collaborate with providers to clarify diagnoses and procedures according to coding guidelines and organizational policies.

The role supports quality improvement and ongoing education while upholding HIPAA and safety standards. Join a team dedicated to improving community health in Western North Carolina.