Remote Clinical Documentation Specialist II

Cape Fear Valley Health System; United States; On-site; USD 85,000 - 120,000; Full time

Job summary

Cape Fear Valley Health System seeks a CDIS professional to facilitate clinical documentation accuracy for DRG reimbursement. You will work with physicians, nurses and coding staff to ensure accurate severity of illness in patient records.

Responsibilities include reviewing charts, educating teams on documentation opportunities, and ensuring regulatory compliance while maintaining patient privacy.

Qualifications

• Association/ Bachelor's nursing degree required or equivalent; RN licensure in NC or compact/multi-state.
• 5 years of inpatient hospital nursing experience with 1 year in critical care required for RN candidates.
• MD/DO candidates must be pursuing their degree; 4 years inpatient hospital experience for MD/DO candidates.
• 2 years ICD-10 CDIS experience required.

Responsibilities

• Identify principal diagnosis, MCC/CCs to reflect severity of illness and ROM per regulations.
• Modify clinical documentation to support clinical severity and service rendered.
• Review coding/clinical issues with staff to assign DRG.
• Perform follow-up reviews of clinical docs every 24–48 hours as indicated.
• Communicate with physicians to clarify documentation needing detail for severity.

Skills

English proficiency

Verbal communication

Written communication

Critical thinking

Team collaboration

Problem solving

Adaptability

Etiquette/confidentiality

Interdisciplinary coordination

Education

Associate’s degree in Nursing

Bachelor’s degree in Nursing (preferred)

MD/DO or IMD/MBBS (preferred)

RN licensure in NC or multi-state license

Tools

Epic Secure Chat

Microsoft Windows

Keyboarding

Job description

Cape Fear Valley Health System seeks a CDIS professional to facilitate clinical documentation accuracy for DRG reimbursement. You will work with physicians, nurses and coding staff to ensure accurate severity of illness in patient records.

Responsibilities include reviewing charts, educating teams on documentation opportunities, and ensuring regulatory compliance while maintaining patient privacy.