Clinical Documentation Specialist II- Health Information Management, Full Time Days

Cape Fear Valley Health; Fayetteville (NC); On-site; USD 60,000 - 80,000; Full time

Job summary

Cape Fear Valley Health is seeking a Clinical Documentation Specialist II to enhance clinical documentation through in-depth reviews and interactions with healthcare teams. This full-time position requires significant experience in clinical settings and aims to support accurate reimbursement and compliance in documentation practices.

Qualifications

• Minimum five (5) years clinical experience in a hospital setting.
• At least one (1) year critical care experience or relevant coding experience preferred.

Responsibilities

• Facilitate clarification of clinical documentation through concurrent reviews.
• Ensure compliance with regulatory guidelines and provide education on documentation.

Skills

Critical thinking

Communication

Education

Registered Nurse (RN) or medical/osteopathic doctorate (MD/DO)

Job description

Clinical Documentation Specialist II- Health Information Management, Full Time Days

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Clinical Documentation Specialist II- Health Information Management, Full Time Days

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Summary

Facilitate 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, will provide educational requirements on clinical documentation to all members of the interdisciplinary care team, while ensuring compliance with regulatory guidelines be maintained.

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Professional

Work Shift

Days (United States of America)

Summary

Facilitate 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, will provide educational requirements on clinical documentation to all members of the interdisciplinary care team, while ensuring compliance with regulatory guidelines be maintained.

Education And Formal Training

Prefer a graduate from an accredited school with an unencumbered active license in the state of North Carolina or as part of Nursing Licensure Compact (NLC) states as an RN, or medical/osteopathic doctorate (MD/DO) or an international qualified physician is a consideration (IMD/MBBS), as this is not a position requiring any clinical patient care duties.

Work Experience

Minimum of five (5) years recent clinical experience in a hospital setting with at least one (1) year critical care experience (i.e. ED, ICU, etc.) or four (4) years working experience in a hospital setting while obtaining medical/osteopathic doctorate degree (MD/OD) or two (2) years ICD-9/10 Coding experience or one (1) year CDIS experience or two (2) years doing Utilization Review experience preferred.

Knowledge, Skills, And Abilities Required

Requires excellent observation skills, critical analytical thinking, problem solving, plus good verbal and written communication skills. Requires basic knowledge of computers, Microsoft Windows software products and keyboarding skills. Works with highly sensitive information and materials where confidentiality is of utmost importance, must be capable of communicating with people from various professions and backgrounds with tact and diplomacy. Professional, team player, and ability to remain calm under stressful situations.

Physical Requirements

Some light carrying, lifting may be required. Occasional walking required accessing all areas of the medical center. Near visual acuity to proofread hand or type written materials. Reaching, handling and use of fingers to operate office machinery. Position may involve skin, eye, mucous membrane or parental contact with blood or other potentially infectious materials.

Required Licenses And Certifications

RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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