Clinical Documentation Specialist, RN

UNC Health

Kinston, NC

JOB DETAILS
SKILLS
Acute Care, Anatomy, Auditing, Clinical Study Publications, Communication Skills, Computer Systems, Diagnosis-Related Group (DRG), Documentation, Healthcare, ICD-10, MEDITECH, Medical Coding, Medical Records, Medical Terminology, Microsoft Excel, Microsoft Office, Microsoft PowerPoint, Microsoft Word, Nursing, Physiology, Presentation/Verbal Skills, QuadraMed, Quality Management, Registered Nurse (RN), Regulations, The Joint Commission (TJC), Writing Skills
LOCATION
Kinston, NC
POSTED
30+ days ago

Job Description

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:

  • 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.

Responsibilities:

  • 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

Job Details

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.

About the Company

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UNC Health