Clinical Doc Integrity Spec, RN

WakeMed Health & Hospitals; Raleigh (NC); On-site; USD 85,000 - 110,000; Full time

Job summary

WakeMed Health & Hospitals in Raleigh, NC seeks a Clinical Documentation Integrity Specialist to ensure accurate documentation for DRGs, ICD-10-CM/PCS, and HCCs. The role advises physicians and care teams to clarify documentation for compliant coding.

The ideal candidate is a Registered Nurse with a BSN and at least 2 years of acute care experience or 1 year in DRG analysis, supporting coding integrity while upholding AHIMA guidelines.

Qualifications

• Registered Nurse license required (NC).
• Bachelor's degree in Nursing required.
• 2 years clinical experience or 1 year DRG analysis experience required.

Responsibilities

• Maintain accurate, complete documentation to improve DRGs, SOI/ROM, and ICD-10 coding.
• Serve as a resource to physicians and healthcare team on documentation questions.
• Communicate with coding teams regarding documentation clarification and accurate coding.

Skills

Documentation integrity

Clinical education

Physician collaboration

Regulatory knowledge

Education

Bachelor's Degree Nursing

Job description

Overview

The Clinical Documentation Integrity Specialist is responsible for maintaining accurate, complete, concise documentation for improvement and integrity of the healthcare system. Serves as a resource to physicians and other members of the healthcare team in matters relating to DRGs, SOI/ROM, ICD-10 CM/ PCS, HCCs, APCs, and CPT information. Maintains a level of knowledge and understanding of AHIMA guidelines and knowledge of compliance and regulatory agency expectations of compliant queries. Communicates with coding team, senior coding team and outside departments regarding documentation clarification and accurate coding.

Department Description

Serving the community since 1961, WakeMed Health & Hospitals is the leading provider of health services in Wake County. With a mission to improve the health and well-being of our community, we are committed to providing outstanding and compassionate care. For more information, visit www.wakemed.org.

EOE

Licensure

Registered Nurse Required

Education

Bachelor's Degree Nursing Required

Experience

2 Years Clinical - Acute Care Or Coding - Inpatient Or 1 Year Diagnosis-Related Group Analysis Required 2 Years Clinical - Cardiology Or Clinical - Critical Care (ICU/CCU) Required