Clinical Documentation Integrity Specialist

WakeMed Health & Hospitals; Raleigh (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

WakeMed Health & Hospitals is seeking a Clinical Documentation Integrity Specialist to maintain accurate and complete documentation for improvement and integrity of the healthcare system. The role supports DRGs, ICD-10 CM/PCS, HCCs, APCs and CPT information while aligning with AHIMA guidelines and regulatory expectations.

Eligible remote states include NC, FL, GA, SC, SD, TN, TX and VA, reflecting WakeMed's flexible coverage for qualified candidates regionally and nationally.

Qualifications

• Associate's degree required.
• Bachelor's degree preferred.
• Master's degree Physician Assistant preferred.

Responsibilities

• Maintains accurate, complete documentation for DRGs, SOI/ROM, ICD-10 CM/PCS, HCCs, APCs and CPT information.
• Serves as a resource to physicians and other members of the healthcare team regarding documentation clarification and accurate coding.
• Communicates with coding team, senior coding team and outside departments regarding documentation clarification and accurate coding.

Education

Associate's Degree Required

Bachelor's Degree Preferred

Master's Degree Physician Assistant 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.**

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