Job description
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.
Education, Licensure, and Experience:
- Bachelor’s Degree in Nursing
- Associates Degree in Nursing or Health Information Technology/Management
- Bachelors or Associates in Nursing and/or Associates in Health Information Technology preferred
- RN, BSN, RHIT, RHIA, CDIP or CCS.
- 2 years of Healthcare/Medical – Registered Nurse experience in an acute care facility or
- 2 years of Healthcare/Medical – Medical Coder experience in acute care facility.
Location: Nash UNC Health Care · NGH CASE MANAGEMENT
Schedule: Full Time, Days, Days
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