Remote Clinical Documentation Specialist II

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 90,000 - 120,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC is seeking a Clinical Documentation Improvement Specialist to enhance documentation quality for DRG accuracy and SOI/ROM alignment. You will engage physicians and care teams to clarify documentation via Epic and chart reviews, ensuring compliant coding practices.

Responsibilities include education on clinical documentation, collaborating with coding staff, and timely follow-up reviews to support reimbursement and quality reporting.

Qualifications

• Associate’s degree in Nursing required.

Responsibilities

• Identify the most appropriate principle diagnosis, MCC/CCs and quality outcomes to reflect severity of illness and ROM.

Skills

Critical thinking

Analytical skills

Communication

Collaboration

Education

Associate's degree in Nursing

Bachelor's degree in Nursing

RN license North Carolina

Tools

Epic EHR

Epic Secure Chat

Microsoft Windows

Job description

Cape Fear Valley Medical Center in Fayetteville, NC is seeking a Clinical Documentation Improvement Specialist to enhance documentation quality for DRG accuracy and SOI/ROM alignment. You will engage physicians and care teams to clarify documentation via Epic and chart reviews, ensuring compliant coding practices.

Responsibilities include education on clinical documentation, collaborating with coding staff, and timely follow-up reviews to support reimbursement and quality reporting.