Clinical Documentation Improvement Specialist
Clinical Documentation Improvement Specialist
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Job Description
Who We Are:
People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. Central Carolina Hospital is a 137bed acute care hospital with over 100 physicians and more than 500 employees. The hospital offers a wide range of specialties including cardiology orthopedics ophthalmology general surgery obstetrics gynecology emergency medicine gastroenterology hospitalist services nephrology hematology urology podiatry pulmonary medicine and wound care.
From sprawling public art to a robust music scene to nature so big and beautiful Sanford has the smalltown feel while still offering something for everyone. Our downtown is a hub of excitement and activity offering delights to satisfy the foodies art lovers history enthusiasts and more.
Health (Medical Dental Vision) and 401K Benefits for fulltime employees
Competitive Paid Time Off / Extended Illness Bank package for fulltime employees
Employee Assistance Program mental physical and financial wellness assistance
Tuition Reimbursement/Assistance for qualified applicants
Discounts with local vendors
Opportunities for education and training through partnership with Duke LifePointHealthcare
And much more
Position Summary:
Reviews medical records to ensure accurate complete and compliant clinical documentation that reflects the severity of patient conditions and supports appropriate coding and reimbursement. The role collaborates with Providers and Coding teams to issue queries clarify diagnoses and improve documentation practices across the continuum of care.
Essential Functions:
1. Conducts concurrent and retrospective reviews of the medical records to assess the accuracy completeness
and specificity of clinical documentation.
2. Initiates and writes compliant provider queries to clarify diagnoses procedures and clinical indicators when
documentation is incomplete or inconsistent.
3. Collaborate with Physicians advanced practice providers coding professionals and other interdisciplinary team
members to ensure the integrity of clinical documentation.
4. Educates clinical staff on documentation improvement strategies coding implications and regulatory
requirements.
5. Tracks trends and reports query outcomes and documentation metrics to support quality improvement and
compliance initiatives.
6. Maintains current knowledge of ICD10CM/PCS MSDRG and APRDRG methodologies clinical indicators
and payer regulations.
7. Participate in audits clinical documentation team meetings and organizational initiatives to improve
documentation and data quality.
8. Ensures compliance with all applicable coding guidelines CMS regulations and hospital policies related to
clinical improvement.
9. Other duties as assigned
EEOC Statement:
Central Carolina Hospital is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color race sex age religion national origin disability genetic information gender identity sexual orientation veterans status or any other basis protected by applicable federal state or local law
Required Education:
Associates degree is required
Bachelors degree or Masters degree is preferred
Required License:
CDIP or RHIT or CCS or RN in NC or any compact state
Required Experience:
Unclear Seniority
Employment Type
Full-Time
