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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.
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.
Legal Employer: NCHEALTH
Entity: Shared Services
Organization Unit: HIM CDI
Work Type: Full Time
Standard Hours Per Week: 40.00
Salary Range: $32.23 - $46.33 per hour (Hiring Range)
Pay offers are determined by experience and internal equity
Work Assignment Type: Hybrid
Work Schedule: Day Job
Location of Job: US:NC:Raleigh
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 Heath Care System. This is not a State employed position.
Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.
Full Time
Hospital
$61k-76k (estimate)
04/16/2024
07/12/2024
www.unchealthcare.org
Morrisville, North Carolina
15,000 - 50,000
Tom Murray
<$5M
Hospital
The UNC Health Care System is a not-for-profit integrated health care system, founded in 1998, owned by the State of North Carolina and based in Chapel Hill. It exists to further the teaching mission of the University of North Carolina and to provide state-of-the-art patient care. A distinguishing characteristic of UNC Health Care is its association with the UNC-Chapel Hill School of Medicine, a nationally eminent research institution. This relationship gives UNC Health Care a powerful pathway for moving the results of biomedical research from medical school laboratories to patient care settin...gs. UNC Health Care has been granted broad powers by the North Carolina General Assembly to assure its management flexibility and competitiveness in a rapidly changing health care business environment. The enterprise is governed by a board of directors appointed by the University of North Carolina.
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