Clinical Documentation Specialist- HIM IP CDI
4 weeks ago
Become part of an inclusive organization with over 40,000 teammates, 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.
Other Information
Other information:
Education Requirements:
•Associate's degree in Health Information Management, Nursing or related field.
•Successful completion of the Clinical Documentation Specialist Proficiency Test.
Licensure/Certification Requirements:
•Must have one of the following: - AHIMA (American Health Information Management Association) certification - AAPC (American Academy of Professional Coders) certification - ACDIS (Association of Clinical Documentation Improvement Specialists) certification - RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license - Advance Practice Provider (NP or PA) license- Medical Doctor (MD) license
Professional Experience Requirements:
•For Inpatient Clinical Documentation Specialist, three (3) years of inpatient facility medical coding, acute inpatient direct patient care, or inpatient Clinical Documentation Specialist experience.
For Outpatient Clinical Documentation Specialist, three (3) years of outpatient facility medical coding, ambulatory outpatient direct patient care, or outpatient Clinical Documentation Specialist experience.
Knowledge/Skills/and Abilities Requirements:
•Strong knowledge of medical record documentation requirements and coding guidelines in accordance with third party payer, state and federal regulations, or strong acute/ambulatory care clinical knowledge of clinical indicators, disease processes, and treatment. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills. Strong critical thinking and sound judgement in decision making.
Job Details
Legal Employer: NCHEALTH
Entity: Shared Services
Organization Unit: HIM IP CDI
Work Type: Full Time
Standard Hours Per Week: 40.00
Salary Range: $33.04 - $47.50 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:Chapel Hill
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 Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job.
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.
-
Clinical Documentation Specialist- HIM IP CDI
3 weeks ago
Chapel Hill, United States UNC Health Care Full timeJob Description Description Become part of an inclusive organization with over 40,000 teammates, 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...
-
IT Infrastructure Documentation Analyst
3 days ago
Chapel Hill, United States Golden Technology Full timeHiGreetings of the Day!Please find the below needs and let me know your interest.Role: IT Infrastructure Documentation AnalystLocation: Chapel Hill, North CarolinaDuration: Contract positionSUMMARY OF DELIVERABLESIT Infrastructure Documentation: Network diagrams, software application catalog, and asset life cycle analysis.Onboarding and Playbook: A detailed...
-
Infrastructure Documentation Specialist
2 days ago
Chapel Hill, North Carolina, United States Golden Technology Full time**Job Description**The **Golden Technology** is seeking a highly skilled **IT Infrastructure Documentation Analyst** to join their team.This role involves documenting and maintaining the company's IT infrastructure, including network diagrams, software application catalog, and asset life cycle analysis.The successful candidate will have excellent...
-
Open Rank Fixed-Term Faculty(IP)
4 weeks ago
Chapel Hill, United States InsideHigherEd Full timeDepartment:Med-Pulmonary - 411480Posting Open Date:05/23/2024Open Until Filled:YesPosition Type:Permanent Faculty Working Title:Open Rank Fixed-Term Faculty(IP)Appointment Type:Fixed Term FacultyVacancy ID:FAC0005088Full-time/Part-time:Full-Time PermanentHours per week:40FTE:1Position Location:North Carolina, USHiring Range:Dependent on...
-
Clinical Support Specialist
1 week ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeCompany OverviewUNC Health Care is a leading healthcare provider in North Carolina, committed to delivering high-quality patient care and improving the health and well-being of our community. Our team of dedicated professionals works together to provide exceptional care and services to our patients.**Salary and Benefits**The salary range for this position is...
-
Clinical Nurse Specialist
2 days ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeJob Overview:As a Clinical Nurse Specialist with UNC Health Care, you will be part of an inclusive organization that improves the health and well-being of unique communities. This role involves coordinating and delivering patient care utilizing the nursing process in a hospital setting.**Key Responsibilities:**Collaborate with multidisciplinary teams to...
-
Clinical Nurse Specialist
2 days ago
Chapel Hill, North Carolina, United States Host Healthcare Full timeJob Title: Clinical Nurse Specialist - PCUCompany OverviewHost Healthcare is a leading travel healthcare company, dedicated to providing top-notch care and services to our clients. Our team of experts is committed to helping you achieve your career goals while delivering exceptional patient care.Salary InformationThe pay package for this role is highly...
-
Respiratory Therapist Clinical Specialist
4 weeks ago
Chapel Hill, United States UNC Health Care Full timeJob Description 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. Position qualifies for our inpatient Respiratory Care Incentive Program:$15,000 commitment incentive with a three (3) year commitment This position is also...
-
Chapel Hill, North Carolina, United States Golden Technology Full timeRole OverviewThe successful candidate will contribute to the development of a comprehensive knowledge base, enhancing the organization's ability to support and maintain its IT infrastructure. This role offers an opportunity to work collaboratively with the IT team, apply technical writing skills, and contribute to the success of Golden...
-
Pharmacist Clinical Specialist
7 days ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeAbout the JobThis is an exciting opportunity for a highly motivated pharmacist to join our inpatient clinical oncology team as an Inpatient Hematology Oncology Pharmacist Specialist. The successful candidate will play a key role in the management of patients with hematologic malignancies and solid tumors, working closely with physicians, APPs, nurses, and...
-
Clinical Oncology Pharmacist Specialist
3 days ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeCompany OverviewAt UNC Health Care, we are dedicated to improving the health and well-being of the unique communities we serve. As a leading healthcare provider, we strive to deliver exceptional patient care and advance medical knowledge through innovative research and education.Job DescriptionWe are seeking an experienced Inpatient Hematology/Oncology...
-
Clinical Nurse II OR Specialist
3 days ago
Chapel Hill, North Carolina, United States Aureus Group Full timeOpportunity OverviewWe are seeking a Clinical Nurse II OR specialist to join our team for a 13-week travel assignment in North Carolina.Key Responsibilities:Provide high-quality patient care in the perioperative setting with precision and compassion.Collaborate effectively with the surgical team to ensure seamless operations and optimal outcomes.Maintain...
-
Ambulatory Clinical Specialist
7 days ago
Chapel Hill, North Carolina, United States UNC Health Full timeOverviewAt UNC Health, we strive to provide comprehensive care and support to our patients. Our multidisciplinary team is dedicated to delivering exceptional healthcare services.\Job DescriptionThe Clinical Social Worker - Ambulatory II plays a vital role in promoting mental, emotional, and social well-being of our patients. This position requires a strong...
-
Chemical Patent Specialist
18 hours ago
Cherry Hill, New Jersey, United States IP RECRUITER GROUP Full timeAbout Our Company:IP RECRUITER GROUP is a leading recruitment agency specializing in intellectual property professionals. We have a reputation for having integrity and providing results, which has led to exclusive assignments that are not advertised.Job Description:This is a strong opportunity for a qualified and experienced patent attorney or patent agent...
-
Clinical Pharmacist
2 weeks ago
Chapel Hill, United States UNC Health Care Full timeClinical Pharmacist - ED overnights at UNC Health Care summary: The Clinical Pharmacist at UNC Medical Center‘s Emergency Department provides pharmaceutical care to a high volume of patients in a multidisciplinary environment. This role requires assessing medication therapy, making clinical interventions, and overseeing pharmacy operations during evening...
-
Billing Specialist
4 weeks ago
Chapel Hill, United States Della Infotech Full time**Pay Rate BR This position performs dental insurance services for the UNC Adams School of Dentistry. The Dental Insurance Specialist position works in all areas of billing and reimbursement from private dental insurance companies. This position requires specialized knowledge of the insurance industry standards relating to billing and reimbursement in order...
-
Clinical Specialist
3 days ago
Chapel Hill, North Carolina, United States UNC Health Care Full timeAs a Clinical Nurse II on our Transplant 5 West unit at UNC Health Care, you'll join a team of dedicated healthcare professionals who share your passion for delivering exceptional patient care. We're committed to creating a culture of excellence and innovation, where you'll have the opportunity to grow professionally and personally.We're seeking candidates...
-
Clinical Pharmacist
3 weeks ago
Chapel Hill, United States UNC Health Care Full timeClinical Pharmacist - ED overnights at UNC Health Care summary: The Clinical Pharmacist at UNC Medical Center's Emergency Department provides pharmaceutical care to a high volume of patients in a multidisciplinary environment. This role requires assessing medication therapy, making clinical interventions, and overseeing pharmacy operations during evening and...
-
Utilization Management Nurse
3 days ago
Chapel Hill, North Carolina, United States Brighton Health Plan Solutions Full timeJob Summary:The Utilization Management Nurse - Prior Authorization Specialist will be responsible for performing medical necessity reviews on prior authorization requests. This role requires a strong understanding of clinical guidelines, policies, and procedures, as well as excellent communication and collaboration skills. The ideal candidate will have...
-
Clinical Pharmacist
2 weeks ago
Chapel Hill, United States UNC Health Care Full timeAbdominal Transplant Clinical Pharmacist at UNC Health Care summary: The Abdominal Transplant Clinical Pharmacist at UNC Hospitals provides comprehensive pharmaceutical care to adult abdominal transplant patients in a multidisciplinary environment. Responsibilities include medication profile review, pharmacotherapy services, patient counseling, and...