Clinical Documentation Specialist

UNC Health • Goldsboro, NC

1d • Hybrid

About The Position

The Clinical Documentation Specialist analyzes medical records to assess a patient’s clinical status, current treatment plan, and care provided during admission and hospitalization. The role identifies potential gaps in physician documentation and tracks documentation-improvement progress. Working collaboratively with the healthcare team, the specialist facilitates accurate medical-record documentation that reflects the patient’s condition, severity of illness, risk of mortality, services rendered, and medical necessity of resources used.

The position conducts concurrent documentation reviews, communicates with physicians and other caregivers through compliant queries, and works with clinicians and coding staff to improve documentation for MS-DRG and AP-DRG payers. It also monitors documentation for compliance and completeness, supports education of the patient-care team, and uses approved tools and data to track progress and identify opportunities for improvement.

Requirements

• North Carolina Registered Nurse licensure.
• At least 2 years of experience in a Clinical Documentation Specialist role in an acute-care facility, or a coding certification of CCS, CCA, RHIT, or RHIA.
• At least 3 years of experience in an acute-care hospital setting.
• Clinical documentation knowledge related to DRGs, POA, MCCs, and CCs.
• Understanding of coding classification systems, including ICD-9, ICD-10, CPT, and HCPCS.
• Clinical knowledge to read and analyze a patient’s health record.
• Clinical understanding of pharmacology, pathophysiology, laboratory tests, radiology, and disease processes.
• Strong analytical skills.
• Ability to collaborate and communicate with physicians, nursing, and other patient-care teammates.
• Ability to read, write, and communicate effectively in English.
• Proficiency with MS Office and ability to learn new software rapidly.

Nice To Haves

• Bachelor of Science degree in nursing.
• Medical/surgical or critical-care experience.
• Experience with EPIC EMR software.

Responsibilities

• Review documentation and communicate with physicians verbally or through compliant queries to clarify diagnoses, severity of illness, plans of care, and opportunities for more complete documentation.
• Collaborate with the healthcare team and coding staff to ensure diagnoses and comorbid conditions are completely documented and reflect the patient’s clinical status and care; follow up on pending queries and update electronic worksheets.
• Work with clinicians and coders to implement documentation review for MS-DRG and AP-DRG payers on assigned hospital units.
• Use established guidelines to identify opportunities to improve clinician documentation and formulate clear, compliant, concurrent questions for clinicians.
• Use inpatient admission criteria to assign diagnoses that meet acute-care criteria and communicate directly with the attending physician when a diagnosis does not meet those criteria.
• Conduct initial and extended-stay concurrent reviews on selected admissions and meet established productivity targets for CDI record review.
• Inform the direct or indirect supervisor of issues that may compromise policy, procedure, compliance, or the Hospital Ethical Code of Conduct.
• Use designated and approved tools to track progress, physician participation, and feedback.
• Query medical staff and other caregivers as necessary through electronic or verbal communication to obtain accurate and complete physician documentation supporting illness severity and risk of mortality.
• Monitor documentation for core-measure compliance, review targeted diagnoses for appropriateness and completeness, gather data, and provide feedback to appropriate personnel.
• Attend annual reviews and departmental in-services as appropriate.
• Identify focus areas through data analysis and report review.
• Educate patient-care team members on documentation guidelines on an ongoing basis.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed