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UNC Health
Chapel Hill, NC, United States
11 days ago
UNC Health
Chapel Hill, North Carolina, United States
11 days ago

Description

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!

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.

Job 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.

Job 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.


Requirements:

  • 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.
  • Three (3) years of inpatient/outpatient facility medical coding or acute/ambulatory care experience.
  • 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: NC HEALTH

Entity: Shared Services

Organization Unit: HIM CDI 

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job

Location of Job: Raleigh, NC or Chapel Hill, NC

Exempt From Overtime: Exempt: Yes

 



Job Information

  • Job ID: 59891442
  • Location:
    Chapel Hill, North Carolina, United States
    Raleigh, North Carolina, United States
  • Position Title: Clinical Documentation Specialist - HIM CDI
  • Company Name: UNC Health
  • Job Function: Academic Administrator
  • Job Type: Full-Time
Healthcare / Health Services
Chapel Hill , NC , US

UNC Health is an award-winning, not-for-profit integrated health care system that is committed to delivering state-of-the-art health care and outstanding service to patients. From the mountains to the coast, UNC Health is there, providing care to North Carolinians from all 100 counties and from across the country. At UNC Health, we are looking for talented, passionate medical professionals to join our growing community and provide the highest quality care to our patients across North Carolina. UNC Health provides a vari...

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