Clinical Documentation Specialist - CDI & Coding Expert

UNC Health Care; Goldsboro (NC); On-site; USD 70,000 - 90,000; Full time

Job summary

UNC Health Care is seeking a Clinical Documentation Specialist to analyze and audit medical records to ensure accurate, compliant documentation reflecting severity of illness and level of service. The role includes educating clinicians to optimize documentation and adherence to coding guidelines.

The position reports to the Health Care System Supervisor of Clinical Documentation Integrity and requires familiarity with MS-DRG, ICD-10-CM/PCS, CPT, and AHIMA standards, with a strong emphasis on

Qualifications

• Associate's degree in Health Information Management, Nursing or related field.
• Certification in CDI (AHIMA/AAPC/ACDIS) preferred.
• Three years of inpatient or outpatient CDI experience.

Responsibilities

• Perform concurrent inpatient reviews and facilitate documentation to support severity of illness, risk of mortality, hospital acquired conditions, patient safety indicators, and complexity of care.
• Accurately assign MS-DRG, ICD-10-CM/PCS, CPT, and HCPCS codes per guidelines and regulations; use compliant query process.
• Provide education to physicians, clinicians, nurses and staff to improve documentation reflecting accuracy and quality metrics.
• Follow workflow processes and use software systems to ensure accurate data collection for CDI activities and reporting.
• Maintain professional growth by participating in continuing education and staying current with documentation requirements and quality measures.

Skills

Clinical documentation

Coding guidelines

MS-DRG assignment

Staff education

Communication skills

Education

Health Information Management degree

Nursing degree

AHIMA certification

AAPC certification

ACDIS certification

RN license

LPN license

MD/NP/PA license

Tools

N/A

Job description

UNC Health Care is seeking a Clinical Documentation Specialist to analyze and audit medical records to ensure accurate, compliant documentation reflecting severity of illness and level of service. The role includes educating clinicians to optimize documentation and adherence to coding guidelines.

The position reports to the Health Care System Supervisor of Clinical Documentation Integrity and requires familiarity with MS-DRG, ICD-10-CM/PCS, CPT, and AHIMA standards, with a strong emphasis on