Clinical Documentation Specialist

Job Summary: Assist with development and execution of a planned, systemic, system-wide approach to process design and performance measurement, assessment, improvement, and reporting. Perform data collection and analysis, trend identification for assigned clinical outcomes, and present this data at the appropriate meetings as defined or needed. Serve as team member or facilitator, responsible for promoting and monitoring safe, high-quality, cost-effective healthcare with the best clinical outcomes possible. Provide physician and nurse education to achieve compliance with best practice and evidence-based guidelines. Facilitate interdisciplinary collaboration to measure and assess processes and outcomes, and proactively identify potential solutions with the multidisciplinary team and appropriate service line leaders and directors. Gather and disseminate clinical performance improvement information and quality initiatives to the service lines, hospital and medical staff departments and committees. Assist with retrospective reviews and preparation of appeals as indicated. Facilitate peer review activities and integrate review findings with the credentialing and reappointment process as needed. Working closely and having frequent communication with Service Line Medical Directors, Service Line Directors, and Department Heads will be required. Frequent communication and updates with the Manager and Director are required. This position will require leading meetings, analysis of data, and collaboration with a multidisciplinary team for performance improvement activities. This position is for CaroMont Health care system. Remote work may be approved per Manager/Director discretion with VP sign off. Days and times are subject to Manager/Director discretion, organizational needs, and work performance. Employee must have personal computer, complete Teleworking CBL as required, and review/sign the corporate Teleworking agreement (see Teleworking policy 15169), and the Remote Access Policy CDI Inpatient (15146).


Qualification: MSN preferred/BSN required. Current RN license to practice in NC (NC license or multi-state (compact) license). Five (5) years recent nursing experience required; hospital setting with acute care experience strongly preferred. Requires strong, broad-based clinical knowledge & the understanding of pathology/physiology, analytical thinking, problem solving, plus good verbal and written communication. Strongly encouraged to obtain certification (CCDS) after 2 years in the role.


EOE AA M/F/Vet/Disability