Position: Clinical Documentation Specialist
Location: UNC Main Hospital in Chapel Hill, presence is required, with work 1 day a week from home after initial training period
Hours: Full-Time, Days
This position may involve support of various hospitals and health care systems within the UNC Health Care System, but will be employed by Rex Hospital, Inc. (this includes, but is not limited to, for purposes of payroll, health benefits, retirement options, and applicable policies). If selected candidate is currently employed with UNC Health Care System, the candidate will remain on current payroll and benefits platform.
We reimburse for RN credential maintenance.
We provide access to ACDIS for each team member.
We reimburse CCDS credential maintenance every two years.
UNCHCS provides excellent benefits and PTO packages.
Analyzes and audits medical records concurrently to ensure that the clinical information within the medical record is accurate, complete, and compliant. Educates 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, and level of service rendered.
Description of Job Responsibilities:
1.Performs concurrent 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.
2.Accurately assigns the working MS-DRG, ICD-10-CM codes, and ICD-10-PCS codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. Utilizes the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicates and collaborates with clinical and non-clinical staff to expedite the resolution of documentation clarification queries.
3.Provides effective education using tools and during rounds (as required). Supports the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourages open dialogue. Responds to questions, concerns, and requests promptly.
4.Compliantly follows workflow processes and competently utilizes software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.
5.Demonstrates responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintains competence in documentation requirements, coding guidelines, and quality measures.