What are the responsibilities and job description for the Clinical Documentation Specialist, RN position at UNC Health?
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
Legal Employer: Lenoir Health
Entity: UNC Lenoir Health Care
Organization Unit: CDI
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: LENOIR MEM
Exempt From Overtime: Exempt: No
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
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
- Responsible for overall improvement of quality and completeness of medical record documentation through concurrent auditing and evaluation of documentation to adequately reflect care provided and resources used.
- EDUCATION
- B.S. in Nursing or Associate Degree in Nursing required.
- EXPERIENCE
- Minimum of two years experience in ICD-10 coding in an acute care setting with a strong DRG background required. Knowledge of coding, regulatory and The Joint Commission guidelines with a strong clinical background preferred.
- LICENSURE/REGISTRATION/CERTIFICATION
- RN or BSN required. CDIP or CCDS credential preferred.
- OTHER SKILLS AND QUALIFICATIONS
- Advanced knowledge of anatomy, physiology and medical terminology
- Intermediate to advanced knowledge of computer systems
- Microsoft Office (Word, Excel, PowerPoint) experience required
- Excellent written and oral communication skills required
- Developed knowledge of anatomy, physiology and medical terminology, coding and reporting guidelines and ability to apply same
- Previous Quadramed Quantim experience preferred
- Previous Meditech experience preferred
Legal Employer: Lenoir Health
Entity: UNC Lenoir Health Care
Organization Unit: CDI
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: LENOIR MEM
Exempt From Overtime: Exempt: No
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.