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Job ID: 61544
Location: Rocky Mount, NC
Facility/Division: Nash UNC Health Care
Status: Full Time
Shift: Day Job
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.
The Registered Nurse 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 Manager - Case Management. Role may be virtual, hybrid or on site. Specialist role will have some additional quality audits with CDI assignment. Leadership or quality improvement experience preferred.
Responsible for concurrent auditing of medical record documentation to ensure specificity of diagnoses and procedures to adequately reflect care provided, use of resources and diagnoses treated. Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians and clinical staff to support that appropriate reimbursement and clinical severity is captured. Proactively coach physicians and clinical staff in areas where further specificity is needed in documentation. Supports timely, accurate, and complete documentation of clinical information. Educates the physicians and clinical staff on an ongoing basis.
Legal Employer: Nash Hospitals
Entity: Nash UNC Health Care
Organization Unit: NGH Case Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Schedule: Day Job
Location of Job: NASH HC
Exempt From Overtime: Exempt: No
The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.
UNC Health is an equal opportunity and affirmative action employer.
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
All interested applicants are invited to apply for career opportunities. Please refer to our Employment Application Accessibility page if you need a reasonable accommodation to search and/or to apply for a career opportunity.
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