Clinical Documentation Specialist - CMG

Job Summary: Responsible for the coordination of data and clinical documentation compliance to improve clinical documentation integrity. Collaborates directly with Physicians, Advanced Practice providers and HIM Coders where documentation improvement opportunities exist. Reviews clinical documentation in the medical record, through concurrent, prospective and retrospective evaluation, and queries the medical staff and other care givers as necessary to obtain accurate and complete documentation which appropriately supports the severity of patient illness, resource consumption and risk of mortality and readmissions. Ensures the accuracy and integrity of clinical documentation used for measuring and reporting physician and medical center outcomes. Educates all members of the patient care team on an ongoing basis as needed. Participates in ongoing committees as needed.

Qualifications: MSN preferred/BSN required. Current RN license to practice in NC (NC license or multi-state [compact] license). Five (5) years recent nursing experience in a hospital setting, acute care experience strongly preferred. Requires strong, broad-based clinical knowledge & the understanding of pathology/physiology, analytical thinking, problem solving, plus good verbal and written communication. Ability to travel multiple days of the week. Knowledge of Microsoft Excel, Microsoft Word, and Google Suite. Experience in developing and presenting education programs. Capable of critical thinking, reasoning, deduction and inference while displaying the ability to draw accurate conclusions.

EOE AA M/F/Vet/Disability