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Clinical Documentation Specialist I - Boone, United States - UNC Health Appalachian
Description
Join our team where we place patient safety at the top of our priorities,PRN (AS NEEDED POSITION)
Position Summary
The Clinical Documentation Specialist (CDS) 1 is an advisor to clinicians regarding complete and accurate inpatient documentation. Functions as a liaison between clinicians and coders to create a mutual understanding of medical record documentation.
The CDS 1's decisions and actions with patients and families are determined in an ethical manner practicing compassion and respect for the inherent dignity, worth and unique attributes of each person.
Effectively communicates with patients/families, visitors, colleagues, physicians, leadership, and volunteers.All areas of nursing practice and care delivery are provided to achieve and maintain top decile results and outcomes for patient experience, quality, and patient safety.
The CDS 1 follows and adheres to ARHS policies and procedures, regulatory requirements, and standards of behavior.The CDS 1 demonstrates the ARHS Mission, Vision, and Values in action and approaches work in a way that reflects a bias for action, efficiency, and personal accountability.
The CDS 1 demonstrates professional conduct, effective communication, and effective delegation of tasks.Effectively and professionally manages working relationships with coworkers, physicians, and all ARHS team members in a way that promotes a healthy work environment.
Performs duties under general supervision.Always assists coworkers, patients, families, and visitors regardless of the patient assignment, so long as the assistance is in-line with their scope of practice and license.
Position QualificationsMinimum Education
Associate Degree in Health Information Technology required
Bachelor's Degree in Health Information Administration preferred
Experience
3 years of inpatient coding in a large health system with an acute care hospital and/or multi-specialty physician practice coding
2 years of Clinical Documentation Integrity experience preferred
Required Registration/License/Certification
Licensure not required
Registered Health Information Technician preferred
Certified Clinical Documentation Specialist or Certified Documentation Improvement Practitioner preferred
Knowledge, Skills and Abilities
Ability to communicate courteously and effectively with the public, patients, family, staff, and physician and acts within the chain of command, utilizing positive verbal and non-verbal skills
Knowledge of, but not limited to, current coding guidelines and methodologies, MS-DRG, APR-DRG, HCCs; ICD-10-CM/PCS coding guidelines and conventions
Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology, and ancillary test results
Knowledge of the continuum of care provided in the organization
Ability to demonstrate exceptional customer service to patients, family, staff, and physicians
Physical Demands
Lifts, positions, pushes, pulls, and/or transfers up to and greater than 20 pounds
Manual dexterity and mobility
Prolonged, extensive or considerable sitting/standing/walking
Bending, squatting, twisting, and turning
Near acuity:
ability to see clearly at 20 inches or less
Working Conditions
Infrequently exposed to the risk of bloodborne diseases
Frequently exposed to hazards from electrical/mechanical/power equipment, odorous chemicals and specimens, and unpleasant elements (accident, injury, slippery surfaces, uneven surfaces), etc.
Subject to irregular hours (days, evenings, nights, weekends, holidays) and emergenciesContinuous sitting, standing, walking for long periods = to or greater than > 8 hours per shift
Speaking, reading, and writing, expanded > 8 hours per day
Exposed to vibration and cramped spaces > 1-hour day
Frequently per shift:
lifts, carries, pushes, and/or pulls > 30 lbs.
Bends, squats, kneels, twists, turns, and reaches
Frequently per minute:
hand, finger, and wrist repetition and moderate dexterity
Frequently per hour:
exposed to close eye work
Infrequently may be exposed to ionizing/nonionizing radiation exposure, including x-ray and microwave.
Benefits and Compensation
403(b) retirement plan
with employer match.
About UNC Health Appalachian
UNC Health Appalachian, the leader for healthcare in the High Country, comprises three hospitals, 13 medical practices, Seby B. Jones Regional Cancer Center, The Rehabilitation Center, and Appalachian Regional Healthcare Foundation.
UNC Health Appalachian stays committed to promoting health in the High Country, enhancing quality of life, and simply "making life better.
"About UNC Health
UNC Health is a state entity and an affiliated enterprise of the University of North Carolina system, comprised of 14 hospitals, 18 hospital campuses and more than 500 clinics along with the clinical patient care programs of the UNC School of Medicine (SOM).
It exists to improve the health and well-being of North Carolinians and others we serve and to further the teaching mission of the University of North Carolina SOM.
Over the past three years, UNC Health has provided more than $400 million in uncompensated or charity care to the citizens of North Carolina.
Our hospitals have received numerous awards and recognition for quality care, patient safety and the overall patient experience. For more information, please visit
UNC Health Appalachian embraces diversity and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other protected status.
We value a workforce that reflects a variety of backgrounds and perspectives, as it enhances our ability to provide outstanding care.
We welcome and encourage applications from candidates of all backgrounds and experiences.UNC Health Appalachian is committed to providing a fair and inclusive hiring process and a workplace where all team members feel respected and empowered.
If you require accommodations during the application process, please contact us.Employment at UNC Health Appalachian is contingent upon successful completion of a background and drug screen.
For accommodations or additional information, contact
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