Clinical Documents Specialist

Novant Health; North Carolina; On-site; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a Clinical Documents Specialist to enhance provider-based clinical documentation quality. This role requires reviewing acute care medical records, collaborating with healthcare professionals, and ensuring compliance with Clinical Documentation Excellence standards. Applicants should have significant nursing experience and relevant certifications, contributing to exceptional patient care.

Qualifications

• Five years of nursing experience required.
• Two years of Clinical Documentation Improvement preferred.
• Current RN licensure in appropriate state required.

Responsibilities

• Review medical records for documentation improvement opportunities.
• Assist and educate providers to ensure accurate documentation.
• Collaborate with healthcare teams for complete clinical information.

Skills

Adaptability

Teamwork

Communication

Attention to Detail

Education

High School Diploma or GED

BSN, BS/BA

MSN, MA, M.Ed or related graduate degree

Tools

Microsoft Office

Electronic Medical Records

Job description

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Job Summary

The Acute Care, Clinical Documentation Specialist is responsible for improving the quality and completeness of provider-based clinical documentation in the medical record. This role involves reviewing acute care, inpatient, medical records to identify and resolve documentation improvement opportunities in accordance with Clinical Documentation Excellence (CDE) program guidelines. The specialist will assist and educate treating providers to ensure documentation accurately reflects the patient's severity of illness and risk of mortality, supporting reliable clinical outcomes reporting. Responsibilities include assessing clinical documentation through review of medical records, completing diagnosis specificity or validation through compliant query practices, and collaborating with physicians, APPs, and the HIM coding team to ensure clinical information used in profiling and reporting is complete and accurate.

At Novant Health, diversity and inclusion are core values. We engage the strengths of each team member to provide remarkable healthcare to our patients, families, and communities. We invite applicants from all backgrounds to apply.

Responsibilities

• Deliver a remarkable patient experience in every interaction.
• Foster teamwork, engagement, and community involvement.
• Leverage diversity and inclusion to support quality care.
• Foster a safe patient environment following "First Do No Harm" principles.

Qualifications

• High School Diploma or GED required; BSN, BS/BA preferred; MSN, MA, M.Ed, or related graduate degree preferred.
• Five years of nursing experience required.
• Two years of Clinical Documentation Improvement, HIM, or related field preferred.
• One year of Critical Care Inpatient Nursing experience preferred.
• Two years of Acute Care inpatient nursing experience preferred.

Licensure/Certification:

• Current RN licensure in appropriate state required.
• Certified Clinical Documentation Specialist (CCDS) preferred.
• Inpatient coding certifications such as CCS or CCA preferred.
• Certified Documentation Improvement Practitioner (CDIP) preferred.

Additional Skills (required):

• Successful completion of skills validation and competency testing.
• Knowledge of Microsoft Office and electronic medical records.
• Ability to adapt to technology enhancements and process changes.
• Commitment to ongoing education and industry updates.

Additional Skills (preferred):

• Training and development experience, including educational platform development or presentation skills.

Job Opening ID 93129

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Administrative

Industries

• Hospitals and Health Care

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