UNC Health
February 1, 2021
Smithfield, NC
Job Type
Work Setting


Become part of an inclusive organization with over 30,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.


The Senior Clinical Documentation Specialist will be responsible for providing input to the Health System Supervisor of Clinical Documentation Integrity on selecting, motivating, and evaluating Clinical Documentation Specialists. In addition, the Clinical Documentation Specialist Senior will assist in assigning duties and tasks to the Clinical Documentation Specialists. This position will report to the Health Care System Supervisor of Clinical Documentation Integrity.

This position is based out of Johnston Medical Center.

With the potential for remote work after initial training, please note that we only employ candidates who currently reside in, or are willing to relocate to one of the following states: Arizona, Arkansas, Florida, Iowa, Kentucky, Maryland, Mississippi, North Carolina, North Carolina, South Carolina, Virginia, Wisconsin



1. Work collaboratively with HCS Manager of CDI, HCS CDI Supervisor, and Clinical Documentation Specialists to reach the goals and objectives of the CDI Program. Actively participate and support the CDI governance structure responsible for achieving clinical and operational excellence, and expected deliverables in relation to the CDI Program.

2. Serve as subject matter expert on CDI workflows, policies and procedures, and applications. Conduct weekly DRG reconciliation meetings with the Clinical Documentation Specialists. Perform monthly quality reviews on CDI workflow processes and data collection of CDI activities.

3. Perform concurrent inpatient reviews and facilitates appropriate clinical documentation to support the severity of illness, expected risk of mortality, hospital acquired conditions, patient safety indicators, and complexity of care rendered to all patients. Perform outpatient reviews and facilitate appropriate clinical documentation to support the severity of illness, hierarchical condition categories, and complexity of care rendered to all patients.

4. Accurately assign the working MS-DRG, ICD-10-CM codes, ICD-10-PCS codes, Hierarchal Condition Categories (HCCs), CPT codes, and HCPCS codes in accordance with the Official Coding Guidelines, and third party payer, state and federal regulations. Utilize the compliant query process according to guidelines, policy, and the AHIMA Standards of Practice. Communicate and collaborate with clinical and non-clinical staff to expedite the resolution of documentation clarification queries.

5. Provide effective education using tools and during rounds and meetings (as required). Support the goals of Clinical Documentation Integrity by building relationships and promoting the importance of documentation. Encourage open dialogue. Respond to questions, concerns, and requests promptly.

6. Compliantly follow workflow processes and competently utilize software systems to ensure accurate data collection and effectiveness of the Clinical Documentation Integrity (CDI) activities for reporting outcomes.

7. Demonstrate responsibility for professional growth and development by actively learning and participating in the continuing education offerings provided. Maintain competence in documentation requirements, coding guidelines, and quality measures.



  • Associate's degree in Health Information Management, Nursing or related field.
  • Successful completion of the Clinical Documentation Specialist Proficiency Test.
  • Three (3) years of CDS experience

Must have one of the following:  


  • AHIMA (American Health Information Management Association) certification
  • AAPC (American Academy of Professional Coders) certification
  • RN (Registered Nurse) license - LPN (Licensed Practical Nurse) license
  • Advanced Practice Provider (NP or PA) license
  • Medical Doctor (MD) license


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.
  • Effective organizational skills, time management, management of multiple priorities, as well as, strong presentation skills.
  • Strong critical thinking and sound judgement in decision making.
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