Join our Talent Network
Skip to main content

*Important Notice:

Applying for Jobs:

Thank you for your continued interest in career opportunities with UNC Health! Please note the following:

  • Current teammates of UNC Health looking to apply for a position outside of their current payroll entity, please close this notice and continue your job search and application as an external applicant. Please be sure to use your personal email address and not your UNC Health email address.
  • Current teammates of UNC Health looking to apply for a position within their current payroll entity, please apply as an internal applicant through Employee Self Service. Teammates applying internally, please be sure to have your teammate ID and UNC Health email address redily availble.

Discovery Teammate Referral Program:

Current teammates, looking to refer someone? Check out our Teammate Referral Program to earn extra cash!

Current teammates, please ensure that you submit your candidate in our system, before they apply. For teammate referral guidelines and eligibility, click here.

myCareer Development Resources:

Current UNC Health teammates also now have access to our myCareer - Career Development Resources, which provide tools and guidance to employees to create a career plan.

Questions:

Need further assistance? Please submit a request through the myHR Portal.

Clinical Documentation Specialist-HMI CDI

This job posting is no longer active.

Job ID: 27281
Location: Smithfield, NC
Facility/Division: Shared Services
Status: Full Time
Shift: Day Job

Did you know UNC Health has Ranked #2 Most Trusted Healthcare Brand in the U.S.? The UNC Health brand was ranked as the #4 healthcare brand in the United States overall and the #2 most trusted healthcare brand, just after Johns Hopkins and before Mass General. Join our One-Great-Team!

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.

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.

**Position is mostly Remote**

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.
2. Accurately assign the working MS-DRG, ICD-10-CM codes, ICD-10-PCS codes, CPT Codes, and HCPCS codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. Utilize the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicate and collaborate with clinical and non-clinical staff to expedite the resolution of documentation clarification queries.
3. Provide effective education using tools and during rounds and meetings (as required). Support the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourage open dialogue. Respond to questions, concerns, and requests promptly.
4. Compliantly follow workflow processes and competently utilize software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.
5. Demonstrate responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintain competence in documentation requirements, coding guidelines, and quality measures.


Other Information

Other information:
Education Requirements:
● Associate's degree in Health Information Management, Nursing or related field.•Successful completion of the Clinical Documentation Specialist Proficiency Test.
Licensure/Certification Requirements:
● Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - ACDIS (Association of Clinical Documentation Improvement Specialists) 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, acute/ambulatory care, or CDS 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:Smithfield

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. This is not a State employed position.
Share: mail
Testimonial: Jackie image
Testimonial: Namoi Hunt image
Testimonial: Letisha Guasp image
Testimonial: Kurt Kremer image
Testimonial: Jacob Jacoby image
Testimonial: Bianca Contreras image
Testimonial: Madeline White image
Testimonial: Thomas Johnson image
Testimonial: Kristin Mooring image
Testimonial: Tamara Leary image
Recent Job Searches
Recently Viewed Jobs

Diversity Statement

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.

Equal Employment Opportunity

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.

To verify employment eligibility, UNC Health is committed to Form I-9 and the E-Verify process.

Learn further E-Verify details in E-Verify (English) or E-Verify (Spanish).

UNC Health supports your right to work. View the Right of Work Statement (English) or Right of Work Statement (Spanish).

View the KNOW YOUR RIGHTS (English) or the KNOW YOUR RIGHTS (Spanish)posters.

View the PAY TRANSPARENCY (English) or the PAY TRANSPARENCY (Spanish)Nondiscrimination provision posters.

View the Federal Workplace poster.