Clinical Documentation Specialist II- Full Time Days

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Professional

Work Shift

Days (United States of America)

Summary

Facilitate clarification to clinical documentation in the medical record; through extensive concurrent reviews with interactions with physicians, nursing staff, other interdisciplinary team caregivers and health information management coding staff, which supports appropriate acuity, resource utilization, quality, severity of illness/risk of mortality (SOI/ROM) and reimbursement. Ensures that clinical severity captured for the level of service rendered to all patients with a DRG based Payor (i.e., Medicare, Medicaid, Commercial, etc.) is accurate.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Identifies the most appropriate principle diagnosis, MCC/CC’s and quality outcomes to accurately reflect severity of illness and risk of mortality (SOI/ROM) in compliance with government regulations

• Facilitates modifications to clinical documentation that support the clinical severity of services, clinical validity rendered to all patients with a DRG base Payor (i.e. Medicare, Medicaid, Commercial, etc.)

• Reviews coding & clinical issues with coding staff to assign the most appropriate working & final DRG

• Completes follow-up/continued stay & potential retrospective reviews of clinical documentation and updates worksheets/findings at least every 24-48 hours or as indicated

• Conducts follow-up/continued stay reviews of clinical documentation to ensure points of clarification documented in the patient’s chart are met

• Assists other team members to ensure completion of all work assignments

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Associate’s degree in nursing required
• Bachelor's degree preferred
• Licensed in North Carolina as Registered Nurse or compact license required
• Medical/osteopathic doctorate or an international qualified physician preferred

Work Experience: 

• 5 years recent clinical experience in a hospital setting with at least 1 year of critical care experience (i.e. ED, ICU, etc.) preferred or

• 4 years working experience in a hospital setting while obtaining medical/osteopathic doctorate degree (MD/OD) preferred

• 2 years ICD-9/10 Coding experience preferred

• 1 year CDIS experience preferred

• 2 years Utilization Review experience preferred

Knowledge, Skills, and Abilities Required: 

• Excellent observation skills

• Critical analytical thinking, problem solving skills

• Verbal and written communication skills

• Basic knowledge of computers, Microsoft Windows software products and keyboarding skills

• Ability to communicate with people from various professions and backgrounds with tact and diplomacy

• Ability to remain calm under stressful situations

Physical Requirements: 

• Some light carrying, lifting may be required

• Occasional walking required to access all areas of the medical center

• Near visual acuity to proofread hand or type written materials

• Reaching, handling and use of fingers to operate office machinery

• Position may involve skin, eye, mucous membrane or parenteral contact with blood or other potentially infectious materials

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Required Licenses and Certifications

RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity