Clinical Documentation Specialist II - Drive DRG Accuracy

Cape Fear Valley Health; Fayetteville (NC); On-site; USD 75,000 - 105,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Clinical Documentation Specialist II to drive accurate clinical documentation through concurrent reviews with physicians, nursing staff, and HIM teams. This role supports appropriate SOI/ROM, DRG accuracy, and compliant reimbursement.

The CDS educates care teams on documentation opportunities and regulatory guidelines, ensuring timely, precise charting and ongoing performance improvement.

Qualifications

• Associate’s degree in Nursing is required.
• Current RN licensure in North Carolina or compact/multi-state license is required.
• Bachelor’s degree in Nursing preferred.
• MD/DO or IMD/MBBS preferred for non-nursing candidates.
• Two years ICD-10 CDIS experience preferred for the CDS role.

Responsibilities

• Identify the most appropriate principal diagnosis, MCC/CCs and quality outcomes to reflect SOI/ROM.
• Facilitate modifications to clinical documentation to support clinical severity and DRG assignments.
• Review coding and clinical issues with staff to assign DRG.
• Complete follow-up/continued stay and retrospective reviews of documentation every 24-48 hours.
• Confer with physicians to clarify information and obtain needed documentation.

Skills

Critical thinking

Communication

Confidentiality

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Education

Associate’s degree in Nursing

Bachelor’s degree in Nursing

MD/DO or international qualified physician (IMD/MBBS)

Tools

Epic

Job description

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Clinical Documentation Specialist II to drive accurate clinical documentation through concurrent reviews with physicians, nursing staff, and HIM teams. This role supports appropriate SOI/ROM, DRG accuracy, and compliant reimbursement.

The CDS educates care teams on documentation opportunities and regulatory guidelines, ensuring timely, precise charting and ongoing performance improvement.