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Clinical Documentation Specialist

Raleigh, NC

Job ID: 1341


Clinical Documentation Specialist

Job Description
This person will be responsible for concurrent review of inpatient medical records to identify opportunities for improving the quality of medical record documentation for reimbursement, severity of illness, and risk of mortality.

Responsibilities include but are not limited to:
  • Identification of cases where diagnoses and procedures are either absent, not stated in appropriate terminology, or are not appropriately recorded.
  • Confer with the appropriate caregiver on the additional documentation that may be required.
  • Identifies cases for Physician Advisor intervention and coordinates the physician advisor reviews and educational opportunities with residents and faculty.
  • Collects the statistics from the reviews and maintains accurate records of review activities to document cost/benefits.
  • Achieve a complete medical record by the time of patient discharge in order to facilitate and enhance the coding and DRG assignment process.
  • Ensures compliance with third party, and State and Federal regulations. 
  • Serves as a liaison between the coding staff and the physicians.
  • Provides coding and documentation educational opportunities for physicians and coding staff.

  • Requires AA/BA/BS degree in Health Information Technology or related field,  AHIMA, AAPC or AAMA certification, 36 months of medical coding or acute care experience.
  • The preferred candidate will have at least 6 years of coding or acute care nursing experience.
  • Successful completion of the Documentation Specialist Proficiency Test;  or RN/LPN license,  36 months of medical coding or acute care experience and successful completion of the Documentation Specialist Proficiency Test.

SourceAbility, Inc. does not discriminate in the acceptance or referral of candidates on the basis of race, color, religion, sex, age, national origin, marital status, disability, or other protected characteristic.

Please contact Tanya Calkins at SourceAbility
704-837-8202 or

SourceAbility, Inc. provides professionals exceptional opportunities to connect with great employers nationwide. We specialize in Management, Information Technology, BI/Analytics, Sales and Marketing and Corporate Functional Operations. Benefit from our experience, excellent service and sound advice.

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