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Clinical Documentation Specialist IP - HIM CDI
UNC Health Care | |
United States, North Carolina, Chapel Hill | |
April 17, 2024 | |
Job Description
Description Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve. Position is hybrid (1 day onsite and 4 days remote). Initial training will be onsite for one week then hybrid. Role may require training onsite to meet business needs. Summary: The Clinical Documentation Specialist will be responsible for analyzing and auditing medical records concurrently to ensure that the clinical information within the medical record is specific, accurate, clinical valid, complete, and compliant. In addition, the Clinical Documentation Specialist will be responsible for educating physicians, non-physician clinicians, nurses, and other staff to facilitate documentation within the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories, and level of service rendered. This position will report to the Health Care System Supervisor of Clinical Documentation Integrity. Responsibilities: 1. Perform concurrent inpatient reviews and facilitates appropriate clinical documentation to support the severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and complexity of care rendered to all patients. Perform outpatient reviews and facilitate appropriate clinical documentation to support the severity of illness, hierarchical condition categories, and complexity of care rendered to all patients. Education Requirements: * For Outpatient Clinical Documentation Specialist, three (3) years of outpatient facility medical coding, ambulatory outpatient direct patient care, or outpatient Clinical Documentation Specialist experience. Knowledge/Skills/and Abilities Requirements: * Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills. Strong critical thinking and sound judgement in decision making. Job Details Legal Employer: NCHEALTH Entity: Shared Services Organization Unit: HIM CDI Work Type: Full Time Standard Hours Per Week: 40.00 Work Schedule: Day Job Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job. Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. |