CDI Specialist: Elevate Clinical Documentation (Hybrid)

Wayne UNC Health Care; Goldsboro (NC); Hybrid; USD 70,000 - 95,000; Full time

Job summary

Wayne UNC Health Care is seeking a Clinical Documentation Specialist who analyzes medical records to ensure accurate documentation of patient status, severity of illness, and resources used. The role collaborates with physicians, coding staff, and the care team to close documentation gaps and support compliant coding for payer requirements.

Ideal candidates have 2+ years in a CDS role in acute care, NC RN licensure (BSN preferred), and experience with EPIC EMR and MS Office.

Qualifications

• Minimum of 2 years’ CDS experience in an acute care setting or coding certification (CCS/CCA/RHIT/RHIA) preferred.
• Minimum of 3 years’ acute care hospital experience required; CDS role experience strongly preferred.
• Registered Nurse licensure in NC preferred; BSN is preferred.

Responsibilities

• Review and improve physician documentation to reflect patient status, treatments, and resources.
• Collaborate with physicians, nursing staff, and coders to ensure complete and compliant documentation.
• Support MS-DRG and AP-DRG payers through accurate documentation review on assigned units.
• Identify improvement opportunities and formulate compliant, concurrent questions for clinicians.
• Monitor documentation quality and compliance with core measures; provide feedback to staff.
• Educate care team on documentation guidelines and HIPAA/privacy requirements.

Skills

Clinical documentation

ICD-9/ICD-10

CPT/HCPCS

Analytical skills

Physician collaboration

MS Office

EPIC EMR

Education

BSN preferred

Tools

EPIC EMR

MS Office

Job description

Wayne UNC Health Care is seeking a Clinical Documentation Specialist who analyzes medical records to ensure accurate documentation of patient status, severity of illness, and resources used. The role collaborates with physicians, coding staff, and the care team to close documentation gaps and support compliant coding for payer requirements.

Ideal candidates have 2+ years in a CDS role in acute care, NC RN licensure (BSN preferred), and experience with EPIC EMR and MS Office.