Clinical Documentation Integrity Specialist

WakeMed; Raleigh (NC); On-site; USD 90,000 - 120,000; Full time

Job summary

WakeMed in Raleigh, NC is seeking a Clinical Documentation Integrity Specialist to maintain accurate, complete documentation for DRG improvement and compliance. The role supports physicians and the care team on ICD-10-CM/PCS, HCCs, CPT, and related coding matters.

You will collaborate with the coding teams, ensure adherence to AHIMA guidelines, and stay updated on regulatory expectations for compliant queries. Eligible remote states are listed, but the position is primarily on-site at WakeMed.

Qualifications

• Associates degree required; higher degrees preferred.
• Knowledge of AHIMA guidelines and compliance expectations.

Responsibilities

• Maintain accurate, concise documentation for DRG, SOI/ROM, ICD-10 CM/PCS, HCCs, CPT information.
• Serve as a resource to physicians and care team for documentation clarification and accurate coding.
• Communicate with coding teams regarding documentation improvement and coding accuracy.

Skills

AHIMA guidelines

Regulatory compliance

Education

Associate's Degree

Bachelor's Degree

Master's Degree (PA preferred)

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.

• Eligible remote states include NC, FL, GA, SC, SD, TN, TX and VA.**

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.

• Eligible remote states include NC, FL, GA, SC, SD, TN, TX and VA.**

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

Licensed Physician Assistant Preferred Registered Health Information Administrator Preferred Registered Health Information Technician Preferred Certified Documentation Improvement Practitioner Preferred Certified Coding Specialist Preferred Certified Clinical Documentation Specialist Preferred

Education

Associate's Degree Required Bachelor's Degree Preferred Master's Degree Physician Assistant Preferred

Experience

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