Job Description

Exciting Clinical Documentation Specialist Opportunity - Raleigh Durham area Health System!

Onsite - Full Time, 1st Shift (M-F, 8 AM - 4:30 PM)  

Join Our Mission: 

Are you passionate about enhancing clinical documentation to improve patient outcomes? Our Health System, located in the vibrant Greater Raleigh Durham area, seeks a dedicated CDI Specialist to join our Health Information Management team. This is your chance to make a significant impact within an acute care setting, working collaboratively with healthcare professionals to ensure the highest standards of care!

About Us:

We pride ourselves on our commitment to quality patient care and excellence in clinical practice. Our team is integral to driving improvements in documentation quality and ensuring compliance with regulations. By joining us, you will be part of a supportive environment that values your expertise and fosters professional growth.

Position Overview:

• Reporting to the Director of HIM, the CDI Specialist will play a crucial role in improving the completeness and accuracy of clinical documentation. 
• Engaging with physicians and patient care providers, you’ll ensure that principal and secondary diagnoses and procedures are documented correctly to promote appropriate DRG, APC, and ER-leveling assignments. 
• Your work will directly contribute to enhancing the healthcare experience for our patients.

Key Responsibilities:

• Conduct concurrent chart reviews during patient admissions, ensuring comprehensive documentation that meets all standards.
• Collaborate with physicians across specialties to deliver tailored learning and support for clinical documentation improvement initiatives.
• Actively resolve documentation-related issues and aid in provider training to enhance compliance and accuracy.
• Review and provide feedback on medical necessity denials while working alongside case managers to capture patients' severity of illness.
• Work closely with the Coding Team to support accurate coding and documentation practices.
• Stay updated with educational offerings related to ICD-10 and CMS guidelines and share vital information with providers.

What We’re Looking For:

Required: 

• Graduation from an accredited nursing program with current RN or LPN licensure in North Carolina. 
• Solid understanding of MS-DRGs and the Inpatient Prospective Payment System IPPS, including CMS guidelines for inpatient admissions.  
• Excellent communication skills, with the ability to convey the importance of precise documentation to physicians.

Preferred:  

• Bachelor of Science in Nursing (BSN) degree.  
• Certification such as CCDS or CCS, or at least 3 years of clinical experience in CDI.  
• Familiarity with Meditech and 3M encoding software.

Ina Phillip is the hot job expert for this search. Apply now and contact Ina at iphillip@ariteam.com or 770-433-2220.