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Clinical Documentation Specialist (Inpatient) - HIM CDI

Company: UNC Health Care
Location: Raleigh
Posted on: August 7, 2022

Job 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.
*This position qualifies for a $10,000 commitment incentive, paid over a three (3) year commitment. The first payment - -will be made within the first thirty (30) days of employment. The remaining will be paid after each six (6) month period of work completed. Learn more here: https://jobs.unchealthcare.org/pages/revenue-cycle-commitment-incentive-program

The Inpatient Clinical Documentation Specialist will report to the Healthcare System Supervisor of Clinical Documentation Integrity.
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. 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.
Location: on-site full time at Rex Hospital


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, Raleigh , Clinical Documentation Specialist (Inpatient) - HIM CDI, Healthcare , Raleigh, North Carolina

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