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Job ID: 11689
Location: Smithfield, NC
Facility/Division: Shared Services
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 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.
** Mostly Remote** occasional onsite
*This position qualifies for a $10,000 commitment incentive, paid over a three (3) year commitment. First Payment will be made within the first thirty (30) days of employment. The remaining will be paid after each six (6) month period of work completed. Learn more here: https://jobs.unchealthcare.org/pages/revenue-cycle-commitment-incentive-program
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.
● 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
Professional Experience Requirements:
● Three (3) years of inpatient/outpatient facility medical coding or acute/ambulatory care 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.
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:Smithfield
Exempt From Overtime: Exempt: Yes
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 employer. As such, UNC Health offers equal employment opportunities to applicants and employees without regard to race, color, religion, sex, national origin, age, genetic information, disability, sexual orientation, gender identity or political affiliation.