Manager Clinical Documentation Specialist- Full Time Days

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); In loco; USD 80.000 - 100.000; Tempo pieno

Descrizione del lavoro

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Health Information Management CDI Program Coordinator to monitor and optimize clinical documentation for DRG-based reimbursement. You will educate medical staff, serve as a preceptor for new hires, and work closely with physicians and coding teams to ensure accurate documentation.

The role emphasizes education, program oversight, and collaboration across clinical teams to improve SOI/ROM capture and reimbursement outcomes.

Competenze

• Associate’s degree in Nursing is required.
• Bachelor’s degree in Nursing is preferred.
• Current RN licensure in North Carolina or compact state required.
• CCDS and/or CDIP certification required or must complete within 1 year of hire.
• 5 years of inpatient hospital experience required with at least 1 year of critical care experience.
• 3 years of ICD-10 inpatient CDI reviewer experience required.
• Knowledge of DRG payor issues and documentation requirements.
• Confidentiality and ability to handle highly sensitive information.

Mansioni

• Oversee and coordinate the CDS specialist processes for daily workflow efficiency.
• Serve as new hire preceptor and provide education and training in the role of train-the-trainer.
• Review performance reports that track the progress of the CDMP program.
• Assist in identifying educational needs for the medical staff and other allied health providers.
• Coordinate ongoing education for physicians and mid-level providers on documentation improvement opportunities.
• Confer with physicians to clarify information and obtain needed documentation.
• Review charts with Senior Coding Specialist and/or Director CDIP and/or Coding and Statistics.
• Other duties as assigned.

Conoscenze

English language proficiency

DRG knowledge

ICD-10 understanding

Critical care experience

Teamwork

Formazione

Associate’s degree in Nursing

Bachelor’s degree in Nursing

Strumenti

Presentation software

Database management

Office software

Descrizione del lavoro

FacilityCape Fear Valley Medical CenterLocationFayetteville, North CarolinaDepartmentHealth Information ManagementJob FamilyNursingWork ShiftDays (United States of America)SummaryMonitors and coordinates CDI Program processes and reviews inpatient medical records for specified payer as directed on admission and throughout hospitalization. Provides education to medical staff, allied health professionals, and hospital ancillary department who document in patients’ medical records. Serves as preceptor and trainer for new hires. Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians, nursing staff, other patient caregivers, and health information management coding staff that support appropriate reimbursement. Ensures that clinical severity is captured for the level of service rendered to all patients with a DRG based payor (Medicare, Medicaid, Champus). Supports timely, accurate, and completed documentation of clinical information used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis.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:Oversee and coordinates the CDS specialist processes for daily workflow efficiencyServe as new hire preceptor and provides education and training in the role of train-the-trainerReview performance reports that track the progress of the CDMP program from the perspective of specialist performance, scheduling, physician response and overall impact of the CDMP programAssist in identification of educational needs for the medical staff and other allied health providers through CDIS reviews, team input and program monitoring reportsCoordinate ongoing education for physicians and mid-level providers on documentation improvement opportunitiesAssist with training internal customers on clinical documentation opportunities, coding, reimbursement issues and performance improvement methodologiesIdentify the most appropriate principal diagnosis and CC’s 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 rendered to all patients with a DRG base payor (Medicare, Medicaid, Champus) and support appropriate reimbursementConfer with physicians to clarify information, obtain needed documentation, present opportunities and education regarding the significance of appropriate documentation needed to support the clinical severity and risk of mortality of the patientReviews charts with Senior Coding Specialist and/or Director CDIP and/or Coding and Statistics if unable to reach agreement with clinical coding specialistsOther 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 preferredCurrent Registered Nurse licensure in North Carolina or compact/multi-state license requiredCCDS and/or CDIP certification required OR must complete certification within 1 year of hireWork Experience:5 years of clinical experience in inpatient hospital setting required with at least 1 year of critical care experience (ED, ICU, etc) required3 years of ICD-10 inpatient CDI reviewer experience requiredKnowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languageKnowledge of DRG payor issues, documentation opportunities and clinical documentation requirementsFlexibility with changing workload/assignmentsPositive teamwork/interpersonal relations in dealing with all members of the team (i.e. co-workers, supervisors, physicians, etc.)Excellent observation, analytical thinking and problem solving skillsGood verbal and written communication skillsBasic knowledge of computers, database management and presentation softwareAbility to work with highly sensitive information and materials where confidentiality is of utmost importanceCapable of communicating with people from various professions and backgrounds with tact and diplomacyProfessional, team player, and ability to remain calm under stressful situationsPhysical Requirements:Some light carrying and/or lifting may be requiredOccasional walking may be 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 pounds#CFVH-2026Required Licenses and CertificationsCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity