Clinical Documentation Specialist

UNC REX Healthcare; Goldsboro (NC); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Wayne UNC Health Care in North Carolina is seeking a Clinical Documentation Specialist to analyze and audit medical records concurrently, ensuring accuracy, completeness, and compliant documentation. The role focuses on severity of illness, risk of mortality, hospital metrics, and coding across inpatient and outpatient settings.

You will educate physicians and staff on documentation practices, assign MS-DRG and ICD-10 codes, collaborate with care teams, and support quality measures.

Qualifications

• Associate degree in Health Information Management, Nursing or related field.
• Successful completion of the Clinical Documentation Specialist Proficiency Test.
• Licensure/certification in AHIMA, AAPC, ACDIS, RN, LPN, NP/PA or MD.
• 3 years inpatient CDS experience or 3 years outpatient CDS experience.

Responsibilities

• Perform concurrent inpatient reviews and facilitate documentation to support severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and care complexity.
• Accurately assign MS-DRG, ICD-10-CM/PCS, CPT, and HCPCS codes per guidelines and third-party payers; use compliant query process and communicate with staff to resolve queries.
• Provide education during rounds and meetings; support CDI goals by building relationships and promoting documentation importance.
• Follow workflow processes and utilize software systems to ensure accurate data collection and CDI activity reporting.
• Demonstrate professional growth by engaging in continuing education and maintaining competence in documentation requirements, coding guidelines, and quality measures.

Skills

Medical coding

Communication skills

Time management

Documentation accuracy

Critical thinking

Presentation skills

Team collaboration

Education

Associate degree in HIM

CDS Proficiency Test

Licensure/Certifications

AHIMA/AAPC/ACDIS certs

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.

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.

Job Summary: The Clinical Documentation Specialist will be responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist will be responsible for educating physicians, non physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. This position will report to the Health Care System Supervisor of Clinical Documentation Integrity.

Description of Job Responsibilities

• Perform concurrent inpatient reviews and facilitates appropriate clinical documentation to support the severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and complexity of care rendered to all patients. Perform outpatient reviews and facilitate appropriate clinical documentation to support the severity of illness, hierarchical condition categories, and complexity of care rendered to all patients.
• Accurately assign the working MS-DRG, ICD-10-CM codes, ICD-10-PCS codes, CPT Codes, and HCPCS codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. Utilize the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicate and collaborate with clinical and non-clinical staff to expedite the resolution of documentation clarification queries.
• Provide effective education using tools and during rounds and meetings (as required). Support the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourage open dialogue. Respond to questions, concerns, and requests promptly.
• Compliantly follow workflow processes and competently utilize software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.
• Demonstrate responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintain competence in documentation requirements, coding guidelines, and quality measures.

Education Requirements

• Associate's degree in Health Information Management, Nursing or related field.
• Successful completion of the Clinical Documentation Specialist Proficiency Test.
• This job profile is intended to provide a representation of responsibilities required. Employees may be requested to perform job-related tasks other than those specifically presented in this profile.
• Job Profile Licensure/Certification Requirements: Must have one of the following:
• AHIMA (American Health Information Management Association) certification
• AAPC (American Academy of Professional Coders) certification
• ACDIS (Association of Clinical Documentation Improvement Specialists) certification
• RN (Registered Nurse) license
• LPN (Licensed Practical Nurse) license
• Advance Practice Provider (NP or PA) license
• Medical Doctor (MD) license

Professional Experience Requirements

• For Inpatient Clinical Documentation Specialist, three (3) years of inpatient facility medical coding, acute inpatient direct patient care, or inpatient Clinical Documentation Specialist experience.
• For Outpatient Clinical Documentation Specialist, three (3) years of outpatient facility medical coding, ambulatory outpatient direct patient care, or outpatient Clinical Documentation Specialist experience.

Knowledge, Skills, and Abilities Requirements

Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills. Strong critical thinking and sound judgement in decision making.

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