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Inpatient Clinical Documentation Specialist - HIM CDI

Company: UNC Health Care
Location: Chapel Hill
Posted on: January 13, 2022

Job Description:

Description Become part of an inclusive organization with over 30,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.The Clinical Documentation Specialist is 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 is 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 System Supervisor of Clinical Documentation Integrity.
Please note that this position isfull-time onsite.

  • Associate's degree in Health Information Management, Nursing or related field.
  • Three (3) years of inpatient/outpatient facility medical coding or acute/ambulatory care experience.
  • Successful completion of the Clinical Documentation Specialist Proficiency Test.Must have one of the following:
    • AHIMA (American Health Information Management Association) certification
    • AAPC (American Academy of Professional Coders) certification
    • RN (Registered Nurse) license
    • LPN (Licensed Practical Nurse) license
    • Advance Practice Provider (NP or PA) license
    • Medical Doctor (MD) license with applicable credential

Keywords: UNC Health Care, Chapel Hill , Inpatient Clinical Documentation Specialist - HIM CDI, Other , Chapel Hill, North Carolina

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