Hybrid Clinical Documentation Specialist

UNC Health; Goldsboro (NC); Hybrid; USD 65,000 - 95,000; Full time

Job summary

Wayne UNC Health Care, part of UNC Health, seeks a Clinical Documentation Improvement professional to analyze medical records, collaborate with physicians and coding staff, and drive documentation accuracy to support DRG reporting.

The role requires CDS experience in acute care, familiarity with DRG guidelines, and strong communication with clinicians. Hybrid work arrangement and day shifts available at Wayne Med campus.

Qualifications

• Minimum 2 years' CDS experience in an acute care facility or coding certification (CCS/CCA/RHIT/RHIA) required.
• Minimum 3 years' experience in acute care hospital setting.
• Medical/Surgical or critical care experience preferred.

Responsibilities

• Reviews documentation and communicates with physicians to clarify diagnosis and plan of care.
• Collaborates with healthcare team and coding staff to ensure complete diagnoses reflect patient status.
• Implements documentation review for MS-DRG and AP-DRG payers on assigned hospital units.
• Utilizes guidelines to identify opportunities for improvement in clinician documentation and to prepare clear questions.
• Queries medical staff to obtain accurate documentation supporting severity of illness and risk of mortality.

Skills

Clinical documentation

Coding knowledge

Medical record analysis

Pharmacology knowledge

Analytical skills

Team collaboration

English communication

MS Office / EPIC

Education

BSN preferred

Tools

EPIC EMR

MS Office

Job description

Wayne UNC Health Care, part of UNC Health, seeks a Clinical Documentation Improvement professional to analyze medical records, collaborate with physicians and coding staff, and drive documentation accuracy to support DRG reporting.

The role requires CDS experience in acute care, familiarity with DRG guidelines, and strong communication with clinicians. Hybrid work arrangement and day shifts available at Wayne Med campus.