Responsible for coordinating the Clinical Documentation team in concurrent reviews of medical record documentation to ensure specificity of diagnoses and procedures reflect the care provided, severity of illness, and conditions treated. Communicates with physicians and physician extenders regarding missing, incomplete, unspecific, unclear, or conflicting documentation. Gathers and analyzes information pertinent to documentation findings and outcomes of communications and shares with management as needed. Works as a pivotal team member with HIM, PFS, Case Management, and Quality Reporting staff to ensure complete and concise documentation is captured in medical records. Daily oversight of workflow, processes, and monitoring all members of the Clinical Documentation Improvement (CDI) team. Maintains staff metrics and provides feedback to management.
Department Description
Serving the community since 1961, WakeMed Health & Hospitals is the leading provider of health services in Wake County. With a mission to improve the health and well-being of our community, we are committed to providing outstanding and compassionate care. For more information, visit www.wakemed.org.
EOE
Licensure
Registered Health Information Administrator Or Registered Health Information Technician Or Physician Assistant National Certifying Exam Eligible Or Certified Nurse Practitioner Or Certified Documentation Improvement Practitioner Or Certified Coding Specialist Or Licensed Physician Assistant Required
Education
Bachelor’s Degree Health Information Management Or Nursing Or Physician Assistant Required – And Master’s Degree Healthcare Or Nursing Preferred
**Eligible remote states include NC, FL, GA, SC, SD, TN, TX and VA.**
Experience
2 Years Clinical – Acute Care Or 2 Years Coding And Diagnosis-Related Group Analysis Required
