Clinical Documentation Specialist

UNC Health; Goldsboro (NC); Hybrid; USD 65,000 - 95,000; Full time

Job summary

Wayne UNC Health Care, part of UNC Health, seeks a Clinical Documentation Improvement professional to analyze medical records, collaborate with physicians and coding staff, and drive documentation accuracy to support DRG reporting.

The role requires CDS experience in acute care, familiarity with DRG guidelines, and strong communication with clinicians. Hybrid work arrangement and day shifts available at Wayne Med campus.

Qualifications

• Minimum 2 years' CDS experience in an acute care facility or coding certification (CCS/CCA/RHIT/RHIA) required.
• Minimum 3 years' experience in acute care hospital setting.
• Medical/Surgical or critical care experience preferred.

Responsibilities

• Reviews documentation and communicates with physicians to clarify diagnosis and plan of care.
• Collaborates with healthcare team and coding staff to ensure complete diagnoses reflect patient status.
• Implements documentation review for MS-DRG and AP-DRG payers on assigned hospital units.
• Utilizes guidelines to identify opportunities for improvement in clinician documentation and to prepare clear questions.
• Queries medical staff to obtain accurate documentation supporting severity of illness and risk of mortality.

Skills

Clinical documentation

Coding knowledge

Medical record analysis

Pharmacology knowledge

Analytical skills

Team collaboration

English communication

MS Office / EPIC

Education

BSN preferred

Tools

EPIC EMR

MS Office

Job description

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary: Analyzes the medical record for clinical status of the patient, current treatment plan and care provided on admission and throughout hospitalization to identify potential gaps in physician documentation; tracks progress of documentation improvement and works collaboratively with the healthcare team to facilitate documentation within the medical record that accurately reflects the patient's condition, severity of illness, risk of mortality, services rendered and medical necessity of resources used.

Responsibilities

• Reviews documentation and communicates with physicians verbally or through compliant query practice to clarify diagnosis, severity of illness, plan of care and opportunities for more complete documentation to accurately reflect care.
• Collaborates closely with healthcare team and coding staff to assure documentation of diagnoses and any co-morbid conditions are complete, reflecting patient's clinical status and care. Follows up on pending queries and updates electronic worksheets as needed.
• Works with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units.
• Utilizes the guidelines established to recognize opportunities for improvement in Clinician documentation, and to formulate and generate clear, compliant and concurrent questions to those Clinicians.
• Utilizes inpatient admission criteria to assign diagnoses that meet acute care criteria. In the event that diagnosis does not meet admission criteria, communicates directly with attending physician.
• Conducts initial and extended-stay concurrent reviews on all selected admissions, consistently meeting established productivity targets for CDI record review.
• Informs direct supervisor or indirect supervisor of issues or problems that may compromise policy, procedure, compliance or the Hospital Ethical Code of Conduct.
• Utilizes designated and approved tools to track progress, physician participation and feedback.
• Queries the medical staff and other caregivers as necessary via electronic/verbal communication to obtain accurate and complete physician documentation to supports the severity of patient illness and risk of mortality.
• Monitors documentation for compliance with core measure and reviews targeted diagnoses for appropriateness and completeness. Gathers data and initiates feedback to appropriate personnel.
• Attends annual review and departmental in-services, as appropriate.
• Identifies areas of focus through data analysis and report review.
• Educates members of the patient care team on documentation guidelines on an ongoing basis.

WAYNE

Other information

Education

B.S. Degree in nursing preferred.

Licensure/Certification

North Carolina Registered Nurse Licensure.

Experience

• Minimum of 2 years' experience in CDS role in an acute care facility or coding certification of CCS, CCA, RHIT, or RHIA required.
• Minimum of 3 years' experience in acute care (hospital) setting required.
• Medical/Surgical or critical care experience preferred.

Knowledge, Skills and Abilities

• *Clinical documentation knowledge as it relates to DRGs, POA, MCCs and CCs.
• *Understanding of coding classification systems (ICD-9, ICD-10, CPT, HCPCS).
• *Clinical knowledge to read and analyze a patient's health record.
• *Clinical understanding of pharmacology, pathophysiology, labs, radiology and disease processes.
• *Strong analytical skills.
• *Ability to collaborate and communicate with physicians, nursing, and other patient care teammates.
• *Ability to read, write and communicate effectively in English.
• *Proficient with MS Office and able to learn new software rapidly. Experience with EPIC EMR software preferred.

Valid NC Driver's License: No

If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management.

MR-546

01.8710.MR-546

Job Details

Legal Employer: Wayne Health

Entity: Wayne UNC Health Care

Organization Unit: Health Information Mgmt

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Hybrid

Work Schedule: Day Job

Location of Job: WAYNE MED

Exempt From Overtime: Exempt: Yes

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.