Clinical Documentation Specialist, RN

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.

• Summary:

  • Responsible for overall improvement of quality and completeness of medical record documentation through concurrent auditing and evaluation of documentation to adequately reflect care provided and resources used.

  Responsibilities:

  • Clinical Documentation Specialist improves overall quality and completeness of the medical record. Through concurrent interaction with physicians, nursing staff, case management and medical records coding staff, they facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality and conditions present on admission. Reviews quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in EHR and coding software on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.
  • 
    
  • • EDUCATION
    • A.D.N, B.S.N, or M.S.N with clinical background required.
    • EXPERIENCE
    • Minimum of two years CDI experience preferred. Knowledge of coding, regulatory and The Joint Commissionguidelines with a strong clinical background preferred. Experience working with EPIC preferred. The ability to communicate with physician and hospital staff in a collaborative manner to promote quality improvement is a MUST.
    • LICENSURE/REGISTRATION/CERTIFICATION
    • RN or BSN required. CDIP or CCDS credential preferred.
    • OTHER SKILLS AND QUALIFICATIONS
    • Critical thinking skills
    • Computer savvy
    • Excellent written and oral communication skills required
    • Developed knowledge of anatomy, physiology and medical terminology, coding and reporting guidelines and ability to apply same

Legal Employer: Lenoir Health

Entity: UNC Lenoir Health Care

Organization Unit: CDI

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: LENOIR MEM

Exempt From Overtime: Exempt: No

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.