[Hiring] Clinical Documentation Specialist II @Cape Fear Valley Health

Role Description

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. This 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. Supports timely, accurate, and completed documentation of clinical information used for measuring and reporting physician and medical center outcomes. On an ongoing basis, CDS will provide educational requirements on clinical documentation to all members of the interdisciplinary care team while ensuring compliance with regulatory guidelines is maintained.

Qualifications

• Associate’s degree in Nursing required
• Bachelor's degree in Nursing preferred
• Medical/Osteopathic Doctorate (MD/OD) or an internationally qualified physician (IMD/MBBS) preferred
• Nurse candidates must have current Registered Nurse licensure in North Carolina or compact/multi-state license required
• Nursing candidates must have 5 years of clinical experience in an inpatient hospital setting
• 1 year of critical care experience (ED, ICU, etc.) required
• Medical/Osteopathic Doctorate (MD/OD) candidates working towards their degree must have 4 years of inpatient hospital setting experience required
• 2 years of ICD-10 CDIS experience required

Requirements

• Proficiency in reading, writing, and speaking the English language
• 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 in stressful situations
• Knowledge of DRG Payor issues, documentation opportunities, and clinical documentation requirements
• Flexible with changing workload/assignments
• Demonstrate positive teamwork/interpersonal relations with all members of teams (coworkers, supervisors, physicians, nurses, etc.)
• Ability to work with highly sensitive information and materials where confidentiality is of the utmost importance
• Remote CDS workers must have and maintain secure space and internet connection

Benefits

• 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 typewritten 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
• Must be able to lift 35 pounds

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.