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CLINICAL DOCUMENTATION SPECIALIST (INPATIENT) - HIM CDI

Job ID: HEA009H0
Location: Smithfield, NC
Facility/Division: SHARED SERVICES
Status: Full-time
Shift: Day Job

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Joining UNC Health Care system means you’ll become part of an inclusive organization with a mission to improve the health and well-being of the diverse communities we serve.

Job Description

Description

The Inpatient Clinical Documentation Specialist will report to the Healthcare System Supervisor of Clinical Documentation Integrity. 
  • 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. 
  • 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. 

Qualifications

  • Associate's degree in Health Information Management, Nursing or related field.
  • Three (3) years of inpatient/outpatient facility medical coding or acute/ambulatory care experience. 
  • Successful completion of the Clinical Documentation Specialist Proficiency Test.

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

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. This is not a State employed position.
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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.

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