Clinical Documentation Specialist II- Full Time days

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 90,000 - 120,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC is seeking a Clinical Documentation Improvement Specialist to enhance documentation quality for DRG accuracy and SOI/ROM alignment. You will engage physicians and care teams to clarify documentation via Epic and chart reviews, ensuring compliant coding practices.

Responsibilities include education on clinical documentation, collaborating with coding staff, and timely follow-up reviews to support reimbursement and quality reporting.

Qualifications

• Associate’s degree in Nursing required.

Responsibilities

• Identify the most appropriate principle diagnosis, MCC/CCs and quality outcomes to reflect severity of illness and ROM.

Skills

Critical thinking

Analytical skills

Communication

Collaboration

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

RN license North Carolina

Tools

Epic EHR

Epic Secure Chat

Microsoft Windows

Job description

FacilityCape Fear Valley Medical CenterLocationFayetteville, North CarolinaDepartmentHealth Information ManagementJob FamilyProfessionalWork ShiftDays (United States of America)SummaryFacilitate clarification to clinical documentation in the medical record; through extensive concurrent reviews with interactions with physicians, nursing staff, other interdisciplinary team caregivers and health information management coding staff, which supports appropriate acuity, resource utilization, quality, severity of illness/risk of mortality (SOI/ROM) and reimbursement. Ensures that clinical severity captured for the level of service rendered to all patients with a DRG based Payor (i.e., Medicare, Medicaid, Commercial, etc.) is accurate. Supports timely, accurate and completed documentation of clinical information, used for measuring and reporting physician and medical center outcomes. On an ongoing basis, CDS will provide educational requirements on clinical documentation to all members of the interdisciplinary care team, while ensuring compliance with regulatory guidelines be maintained.Major Job FunctionsThe following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:Identify the most appropriate principle diagnosis, MCC/CC’s and quality outcomes to accurately reflect severity of illness and risk of mortality (SOI/ROM) in compliance with government regulationsFacilitate modifications to clinical documentation that support the clinical severity of services, clinical validity rendered to all patients with a DRG base Payor (i.e. Medicare, Medicaid, Commercial, etc.)Review coding & clinical issues with coding staff to assign the most appropriate working & final DRGComplete follow-up/continued stay & potential retrospective reviews of clinical documentation and updates worksheets/findings at least every 24-48 hours or as indicatedConduct follow-up/continued stay reviews of clinical documentation to ensure points of clarification documented in the patient’s chart are metConfer with physicians face-to-face, via Epic Secure chat, phone and/or via queries to clarify information in medical record, obtain needed documentation, present opportunities and education regarding the significance of appropriate documentation needed to support the clinical severity of the patientAssist with education for all internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologiesReview charts with Senior Lead CDIS and/or CDIS Director if unable to reach an agreement with Clinical Coding SpecialistsAssists other team members to ensure completion of all work assignmentsOther duties as assignedMinimum QualificationsThe following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:Education and Formal Training:Associate’s degree in Nursing requiredBachelor's degree in Nursing preferredMedical/Osteopathic Doctorate (MD/OD) or an international qualified physician (IMD/MBBS) preferredNurse candidates must have current Registered Nurse licensure in North Carolina or compact/multi-state license requiredWork Experience:Nursing candidates must have 5 years of clinical experience in inpatient hospital setting with 1 year of critical care experience (ED, ICU, etc) requiredMedical/Osteopathic Doctorate (MD/OD) candidates working towards their degree must have 4 years of inpatient hospital setting experience required2 years of ICD-10 CDIS experience requiredKnowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languageExcellent observation skillsCritical analytical thinking, problem solving skillsVerbal and written communication skillsBasic knowledge of computers, Microsoft Windows software products and keyboarding skillsAbility to communicate with people from various professions and backgrounds with tact and diplomacyAbility to remain calm in stressful situationsKnowledge of DRG Payor issues, documentation opportunities and clinical documentation requirementsFlexible with changing workload/assignmentsDemonstrate positive teamwork/interpersonal relations with all members of teams (coworkers, supervisors, physicians, nurses, etc)Ability to work with highly sensitive information and materials where confidentiality is of the utmost importanceRemote CDS workers must have and maintain secure space and internet connectionPhysical Requirements:Some light carrying, lifting may be requiredOccasional walking required to access all areas of the medical centerNear visual acuity to proofread hand or type written materialsReaching, handling and use of fingers to operate office machineryPosition may involve skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materialsMust be able to lift 35 poundsRequired Licenses and CertificationsRN - Board Of NursingCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity