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Email Job Job ID: HEA00992

Job Description

Position:  Clinical Documentation Specialist

Location: UNC Main Hospital in Chapel Hill, presence is required, with work 1 day a week from home after initial training period

Hours: Full-Time, Days

This position may involve support of various hospitals and health care systems within the UNC Health Care System, but will be employed by Rex Hospital, Inc. (this includes, but is not limited to, for purposes of payroll, health benefits, retirement options, and applicable policies). If selected candidate is currently employed with UNC Health Care System, the candidate will remain on current payroll and benefits platform.

We reimburse for RN credential maintenance.

We provide access to ACDIS for each team member.

We reimburse CCDS credential maintenance every two years.

UNCHCS provides excellent benefits and PTO packages.

Job Summary:

Analyzes and audits medical records concurrently to ensure that the clinical information within the medical record is accurate, complete, and compliant. Educates 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, and level of service rendered.

Description of Job Responsibilities:

1. Performs concurrent 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. 

2. Accurately assigns the working MS-DRG, ICD-10-CM codes, and ICD-10-PCS codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. Utilizes the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicates and collaborates with clinical and non-clinical staff to expedite the resolution of documentation clarification queries. 

3. Provides effective education using tools and during rounds (as required). Supports the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourages open dialogue. Responds to questions, concerns, and requests promptly. 

4. Compliantly follows workflow processes and competently utilizes software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.

5. Demonstrates responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintains competence in documentation requirements, coding guidelines, and quality measures.


Associate's degree in Health Information Management, Nursing or related field. Successful completion of the Clinical Documentation Specialist Proficiency Test.


Must have one of the following:

- AHIMA (American Health Information Management Association) certification

- AAPC (American Academy of Professional Coders) certification

- RN (Registered Nurse) license

- LPN (Licensed Practical Nurse) license

- Advance Practice Provider (NP or PA) license

- Medical Doctor (MD) license with applicable credential


Three (3) years of inpatient/outpatient facility medical coding or acute/ambulatory care experience required.


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 judgment in decision making.

Primary Location: Chapel Hill, North Carolina, United States

Department: REXH-28125-Rex HIM Shared Services

Shift: Day Job

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