Clinical Documentation Specialist II

Clinical Documentation Specialist II
- Full Time Days

Join to apply for the Clinical Documentation Specialist II
- Full Time Days role at Cape Fear Valley Health.

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 support 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.

Facility Cape Fear Valley Medical Center

Location Fayetteville, North Carolina

Department Health Information Management

Job Family Professional

Work Shift Days (United States of America)

Major Job Functions

• Identifies the most appropriate principal 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

• 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 internationally qualified physician preferred.
• 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.