Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days

Atrium Health; Charlotte (NC); Hybrid; USD 70,000 - 132,000; Full time

Job summary

A leading healthcare provider is seeking a Compliance Documentation Improvement Specialist (RN) to enhance clinical documentation accuracy. The role involves collaborating with healthcare teams, educating staff on guidelines, and ensuring compliance with coding standards. Ideal candidates will have a strong nursing background and critical thinking skills.

Qualifications

• 5 years of related nursing experience preferred.
• Clinical experience within the assigned population.
• Strong financial and analytical skills preferred.

Responsibilities

• Assist providers to ensure documentation reflects patient severity and service level.
• Work collaboratively with healthcare team for accurate documentation.
• Educate team on documentation guidelines and coding requirements.

Skills

Critical Thinking

Clinical Knowledge

Communication

Education

Bachelor’s Degree

Registered Nurse North Carolina Licensure

Tools

Word

Outlook

Excel

Job description

Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days

Join to apply for the Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days role at Atrium Health

Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days

1 week ago Be among the first 25 applicants

Join to apply for the Compliance Documentation Improvement Specialist (RN) Atrium Health Pineville Hybrid FT Days role at Atrium Health

Job Summary

Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered. Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.

Overview

Job Summary

Assists treating providers to ensure documentation in the medical record accurately reflects the severity of illness of the patient as well as the level of service rendered. Uses clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a multidisciplinary team process. Works collaboratively with physicians and advanced practice providers to ensure the clinical information within the medical record is accurate, complete, and compliant. Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.

Essential Functions

• Reviews selected populations of inpatient medical records to identify the principal and/or secondary diagnoses. Appropriately assigns the MS-DRG that most accurately reflects the severity of illness of the patient based upon the clinical evidence documented at the time of the record review.
• Demonstrates knowledge and understanding of severity based DRG systems; All Patient Refined and Medicare Severity (AP-DRG) and Medical Severity Diagnostic Related Group System (MS-DRG).
• Demonstrates the ability to utilize the licensed software tool to perform and record daily medical record reviews.
• Interacts with the physician and/or other designated members of the healthcare team to ensure that vague or incomplete documentation is clarified within the medical record in a timely manner.
• Works with other departments such as coding, corporate compliance, quality, and finance to support Corporate Goals.
• Participates in the ongoing education of physicians, nurse practitioners, physician assistants and other healthcare team members to identify medical record documentation improvement opportunities employing conflict resolution skills as necessary.
• Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
• Ensures that all written requests to physicians for additional documentation support Corporate Compliance policies.
  
  

Physical Requirements

Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds. Intact sight and hearing with or without assistive devices are required. Ability to speak English fluently and write in understandable terms.

Education, Experience And Certifications

Registered Nurse North Carolina Licensure required. Bachelor’s Degree Required. Appropriate professional certification required within 3 years of hire date per department protocol. 5 years of related nursing experience preferred. Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background helpful. Strong financial and analytical skills preferred. Word, Outlook, Excel experience preferred.

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Finance and Sales

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at Atrium Health by 2x

Get notified about new Compliance Specialist jobs in Charlotte, NC.

Compliance Testing Specialist, Independent Compliance Testing

Charlotte, NC $70,400 - $132,000 2 days ago

Compliance Manager, Regulatory Change Management

Charlotte, NC
$105,600.00
-
$198,000.00
1 week ago

Senior Compliance Specialist, Risk Assessment

Charlotte, NC
$86,400.00
-
$162,000.00
1 week ago

Charlotte, NC
$60,000.00
-
$70,000.00
1 week ago

Regional Compliance Specialist (TN, GA and NC)

Charlotte, NC
$124,800.00
-
$214,500.00
1 week ago

Charlotte, NC
$65,000.00
-
$100,000.00
17 hours ago

Compliance Documentation Improvement Specialist (RN) Atrium Health Cabarrus Hybrid FT Days

SENIOR COMPLIANCE SPECIALIST (CHARLOTTE, NC)

Compliance and Reporting Specialist Ed Partnerships

Compliance Officer – Securities Supervision

Senior Business Controls Compliance Manager

Regulatory Compliance, Centralized Licensing Lead

Lead Contract Administrator (fully remote work options)

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.