Position: Clinical Documentation Specialist
Location: Main Hospital, presence is required, with work 1 day a week from home after initial training period
Hours: Full-Time, Days
This position may involve support of various hospitals and health care systems within the UNC Health Care System, but will be employed by Rex Hospital, Inc. (this includes, but is not limited to, for purposes of payroll, health benefits, retirement options, and applicable policies)
The Clinical Documentation Specialist is responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality.
Opportunities include identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded.
Opportunities may also be identified through focused audits as requested of a service or specialty.
The Specialist will confer with the appropriate caregiver on the additional documentation that may be required. The Specialists identifies cases for Physician Advisor intervention and coordinates the physician advisor reviews and educational opportunities with residents and faculty.
The Specialists collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits. The Specialist's goal is to achieve a complete medical record by the time of patient discharge in order to facilitate and enhance the coding and DRG assignment process.
Ensures compliance with third party, and State and Federal regulations. Serves as a liaison between the coding staff and the physicians.
Provides coding and documentation educational opportunities for physicians and coding staff.

Requires AA/BA/BS degree in Health Information Technology or related field, AHIMA, AAPC or AAMA certification, 36 months of medical coding or acute care experience and successful completion of the UNCH Documentation Specialist Proficiency Test;or
RN/LPN license,36 months of medical coding or acute care experience and successful completion of the UNCH Documentation Specialist Proficiency Test.

Primary LocationUnited States-North Carolina-Chapel Hill
ShiftDay Job

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