Clinical Documentation Auditor

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.

UNC Health Nash, an affiliated member of the UNC Health system, invites passionate healthcare professionals to join our esteemed team. Governed locally, we proudly serve a diverse patient base, spanning Nash, Edgecombe, Halifax, Wilson Counties, and beyond. With a steadfast commitment to elevating community health through exceptional care, we prioritize excellence, compassion, and innovation, ensuring every individual receives the highest standard of support. Joining our team means becoming an integral part of our dedication to wellness, where we constantly strive to redefine excellence in healthcare through state-of-the-art facilities and pioneering programs. Join us in this transformative journey, where your contributions will make a lasting impact on our community's health and wellbeing.

Summary:
Responsible for concurrent auditing of medical record documentation to ensure specificity of diagnoses and procedures to adequately reflect care provided, use of resources and diagnoses treated. Facilitate modifications to clinical documentation through extensive concurrent interaction with physicians and clinical staff to support that appropriate reimbursement and clinical severity is captured. Proactively coach physicians and clinical staff in areas where further specificity is needed in documentation. Supports timely, accurate, and complete documentation of clinical information. Educates the physicians and clinical staff on an ongoing basis.

Responsibilities:
1.Responsible for concurrent auditing of medical record documentation to ensure specificity of diagnoses and procedures to adequately reflect care provided, use of resources and diagnoses treated.
2.Proactively and professionally communicates and coaches physicians and clinical staff on areas of documentation needing further specificity to reflect the care provided, use of resources and diagnoses treated.
3.Promotes departmental objectives through cooperative teamwork and quality performance.
4.Operates equipment and maintains work areas.
5.Acquires age-specific knowledge necessary to provide appropriate level of service and communications.
6.Takes an active role in self-development.
7.Performs other duties, as needed.

Other information:
Education Requirements:
*Bachelor's in nursing, Associate's in nursing or Associate's in healthcare health information technology/management.
Licensure/Certification Requirements:
*RHIT, RHIA, CDIP or CCS.
Professional Experience Requirements:
*2 years' experience in Healthcare as a Registered Nurse or LPN in an acute care facility.
*2 years' experience in Healthcare as a Medical Coder in an acute care facility.
*Experience as a Clinical Documentation Auditor is preferred.

Legal Employer: Nash Hospitals

Entity: Nash UNC Health Care

Organization Unit: NGH Case Management

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: NASH HC

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.