Clinical Documentation Specialist – HIM CDI (Hybrid)

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Position is hybrid (1 day onsite and 4 days remote). Initial training will be onsite for one week then hybrid. Role may require training onsite to meet business needs.


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.

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.


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 CDI

Work Type: Full Time

Standard Hours Per Week: 40.00

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 if you need a reasonable accommodation to search and/or to apply for a career opportunity.

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