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Clinical Documentation Spec - Clinical Documentation

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2131 South 17Th Street
Wilmington, NC
Job ID: 3409
Date Posted: Jul 7, 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: 8HR DAY - Most of shift btwn 7A-3P

Exempt from Overtime: Exempt: Yes

What You'll Do


The Documentation Specialist is a Professional Registered Nurse with a broad clinical knowledge base and understanding of DRG documentation requirements who works under the supervision of the CDI Manager. Responsibilities include 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, accurately reflects the severity of illness for the patient, and is reflective of current CMS standards. Interacts with and provides education to the medical staff regarding documentation.


1. Completes Initial and follow-up medical record review using an organized approach to survey admit notes, past medical history, home meds, physician/provider documentation, treatments, orders, ancillary department notes, laboratory data, and other pertinent components of the clinical record. 2. Analyzes and interprets clinical data to identify gaps, inconsistencies, and/or opportunities for improvement in the clinical documentation and appropriately queries the provider using the concurrent query process. Follows up to ensure queries are answered. 3. Assigns the appropriate DRG, MCC's and CC's to each record reviewed in the CDI documentation system (3MCDIS). 4. Identifies potential HAC’s and PSI’s, documenting in the encoder to flag for review. Appropriately queries the provider using the concurrent query process. Follows up as deemed necessary by the HAC Steering Committee. 5. Regularly interacts with/educates physicians to enhance understanding of the CDI program and to ensure the medical record can be coded accurately in order to reflect patient severity of illness and risk of mortality. 6. Collaborates with other clinical disciplines and members of the coding department to ensure high quality clinical documentation and efficient, timely coding of the medical record. 7. Collaborates with Coding Department when discrepancies in the medical record are identified and reviews medical record to provide clinical feedback for accurate coding of procedural codes, ICD-CM diagnosis or DRG. 8. Participates in performance improvement activities related to the operational processes for the Documentation Improvement Program as well as related organizational/departmental goals. 9. Develops collaborative relationships and promotes teamwork with co-workers and other departments. 10. Organizes and performs work responsibilities effectively and efficiently. 11. Maintains strict patient confidentiality, adhering to HIPPA guidelines.

Position Requirements

* Registered Nurse
* Cert Clin Doc Specialist
* Cert Coding Specialist
* Reg Records Administrator
* Reg Health Info Technologist

* Associate Degree Nursing
* Bachelor of Nursing

Other information:

Education: Graduation from accredited School of Nursing, or Associates degree in Nursing or health related field required. BSN or Bachelors degree in health related field preferred. 

Licensure / Certifications: Current License to practice professional nursing in State of North Carolina, or CCDS Certification in Clinical Documentation Improvement, or CCS, RHIA, or RHIT preferred. 

Experience: RN-Minimum of 5 years experience in an acute care patient setting. Must be able to demonstrate broad clinical knowledge base necessary to review a wide variety of medical records. 

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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