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Mgr Clinical Documentation Imp - Clinical Documentation

This job posting is no longer active.

2131 South 17Th Street
Wilmington, NC

Date Posted: Mar 2, 2021

Job Description



NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.

About the Job

Location: New Hanover Regional Medical Center

Department: Clinical Documentation

Full Time Equivalent: FTE: 1.000000

Work Type: 64 to 80 Hours Pay Period

Work Schedule: STD HRS - Standard-Exe or Office w flex

Exempt from Overtime: Exempt: Yes

What You'll Do


Responsible for the leadership, planning, daily operation, employee relations, maintenance of standards of performance, and customer satisfaction for Clinical Documentation Improvement program (CDI) at New Hanover, and Cape Fear and Women and Children’s Hospitals under the direction of the Director of Clinical Resource Services. The CDI program includes providing concurrent medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation; collaborating with Case Managers, Outcomes, Managers, and Coding Department to assure documentation is clinically appropriate and reflective of current CMS standards; providing education to medical staff regarding documentation.


1.Directs hospital based Clinical Documentation Improvement efforts provided by RN Documentation Specialist that focus on capturing documentation that accurately reflects the severity of illness and risk of mortality for hospital patients.

2.Responsible for the daily operations of the Documentation Specialist, ensuring that policies, practices, procedures and standards are followed.Makes regular rounds to support the Documentation Specialist in their role, serves as an expert resource.

3.Participates in and supports the attainment and analysis of data to minimize variations in staff work flow and physician documentation patterns to optimize the capture of accurate clinical documentation.

4.Prepares regular reports for the Director to assist in monitoring the effectiveness of the Documentation Specialist’s individual performance and the impact of the overall program.

5.Participates in planning and providing education to the medical staff and service lines related to documentation to assure medical record is reflective of accurate medical diagnoses, complications and co-morbidities.

6.Collaborates with Coding Department when discrepancy in medical record is identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-9-CM diagnosis or DRG.

7.Hires and retains competent and service excellence oriented staff.

8.Ensures staffing is sufficient and employees are adequately trained.Responsible for evaluation and disciplinary process.

9.Works collaboratively with the Case Management team to support compliance with Medicare and Medicaid regulations.

10.In coordination with the Director, establishes and monitors departmental objectives relative to the

organizational goals.

11.Maintains budget for program operations within established guidelines.

12.Participates in performance improvement activities related to the operational processes for the

Documentation Improvement Program as well as related organizational/departmental goals.

13.Develops collaborative relationships and promotes team work with co-workers and other departments.

14.Organizes and performs work responsibilities effectively and efficiently.

15.Demonstrates effective leaderships and communication skills.

Position Requirements

* Registered Nurse

* Bachelors Degree

Other information:

Experience: Minimum of 5 years experience as an RN required and minimum one year experience in Clinical Documentation Improvement program or related field such as coding required. Must be able to demonstrate broad clinical knowledge base to review medical records for variety of patient types. Prior leadership/management experience preferred. 

Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence. 

Performs other duties as assigned. 

Individual will possess commensurate combination of education, experience and qualifications.

Other Information

This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.

  • Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve. 
  • Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek. 
  • Forbes America’s Best Large Employers 2018 and 2019Link 
  • Becker’s 150 Top Places to Work in HealthcareLink 
  • Healthgrades Outstanding Patient Experience

Consider a career at NHRMC and become part of this award winning team!

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