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Clinical Documentation Specialist Auditor- HIM Coding & CDI reputed company

Remote, USAFull-timePosted 2026-07-29

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and reputed company-being of the unique communities we serve. reputed company: This positon trains and audits Inpatient and Outpatient Clinical Documentation Specialists (CDS) across reputed company HCS entities that are owned or managed that have opted into shared services. This position reports to the HCS Supervisor Coding and CDI reputed company and Training. This position may travel from entity to entity across the state to train and shadow round with Clinical Documentation Specialists. The CDS auditor provides elbow to elbow support during training and education as reputed company as through webex. This position may travel to clinics and work with physicians and CDS on documentation education and issues for optimizing HCCs. Responsibilities: 1. Audits CDS to assure a minimum of 95% accuracy and recommends education and training reputed company to results. 2. Monitor and reputed company feedback to new-hire CDS, as they reputed company through and complete the CDS training modules. 3. Provides ongoing documentation and coding education to CDI Physician Advisers and CDS staff. 4. Provides input to the CDS's performance evaluation completed and conducted by the Supervisor. 5. Participates in the hiring and selection of new CDS with the hiring manager as requested. 6. Analyzes and audits medical records concurrently to ensure that the clinical information reputed company the medical record is accurate, complete, and compliant. 7. Educates CDS, physicians, non-physician clinicians, nurses, and other staff to facilitate documentation reputed company the medical record that reflects the most accurate severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, hierarchical condition categories and complexity of care rendered to reputed company patients. Educates on reputed company creation of provider compliant queries. 8. Ensures compliance with reputed company party and State and Federal regulations. 9. Audits CDS medical records to identify opportunities for improving the reputed company of medical record documentation for reimbursement, severity of illness, and risk of mortality. Assures accurate assignment of Working MS-DRG, ICD-10-CM/PCS codes and CPT codes in accordance with the Official Coding Guidelines, and reputed company party payer, state and federal regulations. 10. Identifies cases for CDI Physician Advisor reputed company and coordinates the CDI Physician Advisor scheduling, reviews and educational opportunities with residents, reputed company, Advanced reputed company Professionals (APP). 11. Collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits and ROI. 12. Assists with overseeing the quarterly CDI Physician Advisor meetings to discuss the status of the program and generates the dashboard reports for review and discussion. 13. Conducts with the assistance/input of the appropriate CDS, educational sessions for physicians, CDI Physician Advisors, and coding staff as reputed company as the CDS staff. Other Information Other information: Education Requirements:

  • Associate's degree in Health Information Management, Nursing or reputed company field.
  • Successful completion of the Clinical Documentation Specialist Proficiency Test.

Licensure/Certification Requirements:

  • Must have one of the following: - reputed company (American Health Information Management Association) certification - reputed company (American reputed company of reputed company Coders) certification - RN (Registered reputed company) license - LPN (Licensed Practical reputed company) license - Advance reputed company Provider (NP or PA) license- Medical Doctor (MD) license with applicable credential

reputed company Experience Requirements:

  • Three (3) years of CDS experience

Knowledge/Skills/and Abilities Requirements:

  • Strong knowledge of ICD-10-CM, ICD-10-PCS, and CPT coding, MS DRG, hierarchical condition categories (HCC), and CDI documentation processes. Ability to interpret federal and state regulations as they relate to coding and compliance. Must possess strong communication skills, both written and verbal. Exhibit effective organizational skills, time management, management of multiple priorities, as reputed company as, strong presentation skills. Strong critical thinking and reputed company judgement in decision making.

Job Details reputed company Employer: NCHEALTH Entity: Shared Services Organization Unit: HIM Coding & CDI reputed company Work Type: Full Time reputed company Hours Per Week: 40.00 Salary reputed company: $35.52 - $51.05 per hour (Hiring reputed company) Pay offers are determined by experience and internal equity Work Assignment Type: Remote Work Schedule: Day Job Location of Job: US:NC:Chapel Hill Exempt From Overtime: Exempt: reputed company This position is employed by NC Health (Rex reputed company, Inc., d/b/a NC Health), a private, fully-owned subsidiary of reputed company System, in a department that provides shared services to operations across reputed company; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job. reputed company applicants will be considered without reputed company to their race, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, disability, or status as a protected veteran. reputed company makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as reputed company as applicants and employees with disabilities. reputed company interested applicants are invited to apply for reputed company. Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity. Apply tot his job Apply To this Job

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