Senior Clinical Documentation Specialist

Capefearvalley; Fayetteville (NC); On-site; USD 78,000 - 102,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Clinical Documentation Specialist II to facilitate accurate clinical documentation and DRG-based reimbursement through ongoing chart reviews and physician collaboration. The CDS will educate care teams on documentation opportunities and regulatory guidelines to ensure compliant, high-quality coding and reporting.

The role emphasizes collaboration with physicians, nursing staff, and HIM coding, with a focus on timely and accurate

Qualifications

• Associate degree in Nursing is required.
• Bachelor’s degree in Nursing is preferred.
• RN licensure in North Carolina or compact license is required.
• Nursing experience in inpatient hospital setting with 5 years and 1 year critical care is preferred per the job posting.

Responsibilities

• Identify the most appropriate principal diagnosis, MCC/CC’s and quality outcomes to accurately reflect severity of illness and risk of mortality (SOI/ROM) in DRG per government regulations.
• Facilitate modifications to clinical documentation that support the clinical severity of services for DRG payor.
• Review coding and clinical issues with coding staff to assign the most appropriate DRG.
• Complete follow-up/continued stay & retrospective reviews of clinical documentation at least every 24-48 hours.
• Confer with physicians face-to-face, via Epic Secure chat, phone or queries to clarify information in the medical record and educate on documentation.

Skills

English proficiency

Attention to detail

Analytical thinking

Communication skills

Teamwork

Problem solving

Education

Associate's degree in Nursing

Bachelor's degree in Nursing preferred

MD/DO or IMD/MBBS preferred

RN licensure in North Carolina or compact license required

Job description

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Clinical Documentation Specialist II to facilitate accurate clinical documentation and DRG-based reimbursement through ongoing chart reviews and physician collaboration. The CDS will educate care teams on documentation opportunities and regulatory guidelines to ensure compliant, high-quality coding and reporting.

The role emphasizes collaboration with physicians, nursing staff, and HIM coding, with a focus on timely and accurate